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Kelam LM, Wani MA, Dhaked DK. An update on ATP synthase inhibitors: A unique target for drug development in M. tuberculosis. Prog Biophys Mol Biol 2023; 180-181:87-104. [PMID: 37105260 DOI: 10.1016/j.pbiomolbio.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 04/29/2023]
Abstract
ATP synthase is a key protein in the oxidative phosphorylation process, as it aids in the effective production of ATP (Adenosine triphosphate) in all life's of kingdoms. ATP synthases have distinctive properties that contribute to efficient ATP synthesis. The ATP synthase of mycobacterium is of special relevance since it has been identified as a target for potential anti-TB molecules, especially Bedaquiline (BDQ). Better knowledge of how mycobacterial ATP synthase functions and its peculiar characteristics will aid in our understanding of bacterial energy metabolism adaptations. Furthermore, identifying and understanding the important distinctions between human ATP synthase and bacterial ATP synthase may provide insight into the design and development of inhibitors that target specific ATP synthase. In recent years, many potential candidates targeting the ATP synthase of mycobacterium have been developed. In this review, we discuss the druggable targets of the Electron transport chain (ETC) and recently identified potent inhibitors (including clinical molecules) from 2015 to 2022 of diverse classes that target ATP synthase of M. tuberculosis.
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Affiliation(s)
- Lakshmi Mounika Kelam
- Department of Pharmacoinformatics, National Institute of Pharmaceutical Education and Research (NIPER)-Kolkata, Chunilal Bhawan, 168 Maniktala Main Road, Kolkata, 700054, West Bengal, India
| | - Mushtaq Ahmad Wani
- Department of Pharmacoinformatics, National Institute of Pharmaceutical Education and Research (NIPER)-Kolkata, Chunilal Bhawan, 168 Maniktala Main Road, Kolkata, 700054, West Bengal, India
| | - Devendra K Dhaked
- Department of Pharmacoinformatics, National Institute of Pharmaceutical Education and Research (NIPER)-Kolkata, Chunilal Bhawan, 168 Maniktala Main Road, Kolkata, 700054, West Bengal, India.
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Zegarra-Urquia CL, Santiago J, Bumgardner JD, Goroncy AK, Vega-Baudrit J, Hernández-Escobar CA, Zaragoza-Contreras EA. Characterization of isoniazid incorporation into chitosan-poly(aspartic acid) nanoparticles. INT J POLYM MATER PO 2022. [DOI: 10.1080/00914037.2022.2145287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Julio Santiago
- Departamento de Química Orgánica, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Joel D. Bumgardner
- Biomedical Engineering, The University of Memphis, Memphis, Tennessee, USA
| | | | - José Vega-Baudrit
- Centro Nacional de Alta Tecnología “Dr. Franklin Chang Díaz”, Laboratorio Nacional de Nanotecnología (LANOTEC), San José, Costa Rica
- POLIUNA, Escuela de Química, Universidad Nacional, Heredia, Costa Rica
| | - Claudia A. Hernández-Escobar
- Department of Engineering and Materials Chemistry, Centro de Investigación en Materiales Avanzados, Complejo Industrial Chihuahua, Chihuahua, Mexico
| | - E. Armando Zaragoza-Contreras
- Department of Engineering and Materials Chemistry, Centro de Investigación en Materiales Avanzados, Complejo Industrial Chihuahua, Chihuahua, Mexico
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Saderi L, Puci M, Lorenzo BD, Centis R, D’ambrosio L, Akkerman OW, Alffenaar JC, Caminero JA, Chakaya JM, Denholm JT, Kurhasani X, Ong CW, Rendon A, Silva DR, Tiberi S, Zenner D, Cabibbe AM, Migliori GB, Sotgiu G. Rapid diagnosis of XDR and pre-XDR TB: a systematic review of available tools. Arch Bronconeumol 2022. [DOI: 10.1016/j.arbres.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 07/15/2022] [Accepted: 07/15/2022] [Indexed: 11/23/2022]
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Abstract
The terminal oxidases of the oxidative phosphorylation pathway play a significant role in the survival and growth of M. tuberculosis, targeting these components lead to inhibition of M. tuberculosis. Many drug candidates targeting various components of the electron transport chain in M. tuberculosis have recently been discovered. The cytochrome bc1-aa3 supercomplex is one of the most important components of the electron transport chain in M. tuberculosis, and it has emerged as the novel target for several promising candidates. There are two cryo-electron microscopy structures (PDB IDs: 6ADQ and 6HWH) of the cytochrome bc1-aa3 supercomplex that aid in the development of effective and potent inhibitors for M. tuberculosis. In recent years, a number of potential candidates targeting the QcrB subunit of the cytochrome bc1 complex have been developed. In this review, we describe the recently identified inhibitors that target the electron transport chain's terminal oxidase enzyme in M. tuberculosis, specifically the QcrB subunit of the cytochrome bc1 complex.
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Affiliation(s)
- Mushtaq Ahmad Wani
- Department of Pharmacoinformatics, National Institute of Pharmaceutical Education and Research (NIPER)-Kolkata, Chunilal Bhawan, 168 Maniktala Main Road, Kolkata, West Bengal, 700054, India
| | - Devendra Kumar Dhaked
- Department of Pharmacoinformatics, National Institute of Pharmaceutical Education and Research (NIPER)-Kolkata, Chunilal Bhawan, 168 Maniktala Main Road, Kolkata, West Bengal, 700054, India.
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Ahmad I, Jadhav H, Shinde Y, Jagtap V, Girase R, Patel H. Optimizing Bedaquiline for cardiotoxicity by structure based virtual screening, DFT analysis and molecular dynamic simulation studies to identify selective MDR-TB inhibitors. In Silico Pharmacol 2021; 9:23. [PMID: 33854869 DOI: 10.1007/s40203-021-00086-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 01/30/2023] Open
Abstract
Since the last 4 decades, Bedaquiline has been the first drug discovered as a new kind of anti-tubercular agent and received FDA approval in December 2012 to treat pulmonary multi-drug resistance tuberculosis (MDR-TB). It demonstrates excellent efficacy against MDR-TB by effectively inhibiting mycobacterial ATP synthase. In addition to these apparent assets of Bedaquiline, potential disadvantages of Bedaquiline include inhibition of the hERG (human Ether-à-go-related gene; KCNH2), potassium channel (concurrent risk of cardiac toxicity), and risk of phospholipidosis due to its more lipophilic nature. To assist the effective treatment of MDR-TB, highly active Bedaquiline analogs that display a better safety profile are urgently needed. A structure-based virtual screening approach was used to address the toxicity problems associated with Bedaquiline. Among the virtually screened compound, CID 15947587 had significant docking affinity (- 5.636 kcal/mol) and highest binding free energy (ΔG bind - 85.2703 kcal/mol) towards the Mycobacterial ATP synthase enzyme with insignificant cardiotoxicity and lipophilicity. During MD simulation studies (50 ns), the molecule optimizes its conformation to fit better the active receptor site justifying the binding affinity. The obtained results showed that CID15947587 could be a useful template for further optimizing the MDR-TB inhibitor. Supplementary Information The online version contains supplementary material available at 10.1007/s40203-021-00086-x.
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Patel H, Chaudhari K, Jain P, Surana S. Synthesis and in vitro antitubercular activity of pyridine analouges against the resistant Mycobacterium tuberculosis. Bioorg Chem 2020; 102:104099. [PMID: 32711084 DOI: 10.1016/j.bioorg.2020.104099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/11/2020] [Indexed: 01/19/2023]
Abstract
Mycobacterium tuberculosis (MTB) infection has become a growing health risk as multi-drug resistant strain (MDR-MTB) has emerged worldwide. The development of isoniazid (INH)-resistant M. tuberculosis strains dictate the need to re-design this old drug to create effective analogs against the resistant INH strains. Synthesis and the biological activity of isoniazid and pyridine derivatives were successfully carried out with elaborated characterization by spectral data. Amongst the synthesized compounds; 1 and 2 displayed encouraging antimycobacterial activity with IC50 of 3.2 µM and 1.5 µM against the H37Rv strain. The MIC of test compounds 1 and 2 were also assessed against the 5 drug resistant isolates (FQ-R1, INH-R1, INH-R2, RIF-R1 and RIF-R2) of MTB strains under aerobic conditions and compound 1 [MIC = 3.2 µM for FQ-R1; MIC = 140 µM for INH-R1; MIC = 160 µM for INH-R2; MIC = 2.4 µM towards RIF-R1; MIC = 4.2 µM for RIF-R2] and 2 [MIC = 3.3 µM for FQ-R1; MIC = 170 µM for INH-R1; MIC = 190 µM for INH-R2; MIC = 1.8 µM for RIF-R1; MIC = 8.4 µM for RIF-R2] have shown significant activity at non-cytotoxic concentration in comparison to the standard drug.
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Abstract
Given the global burden of tuberculosis, shortened treatment regimens with existing or repurposed drugs are needed to contribute to tuberculosis control. The long duration of treatment of drug-susceptible tuberculosis (DS-TB) is associated with nonadherence and loss to follow up, and the treatment success rate of multidrug-resistant tuberculosis (MDR-TB) is low (approximately 50%) with longer regimens. In this review article, we report recent advances and ongoing clinical trials aimed at shortening regimens for DS-TB and MDR-TB. We discuss the role of high-dose rifampin, as well as that of clofazimine and linezolid in regimens for DS-TB. There are at least 5 ongoing clinical trials and 17 observational studies and clinical trials evaluating shorter regimens for DS-TB and MDR-TB, respectively. We also report the results of observational studies and clinical trials evaluating a standardized nine-month moxifloxacin-based regimen for MDR-TB. Further studies, especially randomized clinical trials, are needed to evaluate regimens including newer drugs, drugs proven to be or highly likely to be efficacious, and all-oral drugs in an effort to eliminate the need for injectable drugs.
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Affiliation(s)
- Denise Rossato Silva
- . Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | | | - Giovanni Battista Migliori
- . Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italia
- . Blizard Institute, Queen Mary University of London, London, United Kingdom
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Wang J, Zhou M, Chen Z, Chen C, Wu G, Zuo Y, Ren X, Chen Z, Wang W, Pang Y. Survival of patients with multidrug-resistant tuberculosis in Central China: a retrospective cohort study. Epidemiol Infect 2020; 148:e50. [PMID: 32070443 DOI: 10.1017/S0950268820000485] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The aim of this study was to evaluate long-term survival and risk factors associated with multidrug-resistant tuberculosis (MDR-TB) patient survival in Central China. Between December 2006 and June 2011, incident and retreatment adult MDR-TB patients were enrolled in the present study. Cox proportional hazard regression analysis was used to evaluate the risk factors affecting survival. The total follow-up period was 270 person-years (PY) for 356 MDR-TB cases in Wuhan. Of the 356 cases, 103 patients died, yielding an average case fatality rate of 381.2 per 1000 TB patients per year. Using adjusted Cox regression analysis, older age (adjusted hazard ratio (aHR) >3.0 starting from 30 years) and low education level (primary and middle school; aHR 1.67 (95% CI 1.01–2.77)) were independently associated with lower survival. Diabetes mellitus profoundly affected the survival of MDR-TB patients (aHR 1.95 (95% CI 1.30–2.93)). Our data demonstrate that coexistent diabetes significantly and negatively impacted MDR-TB patient survival. In addition, MDR-TB patients aged 60 years or older exhibited a greater risk of mortality during follow-up. Our findings emphasise that MDR-TB patients with comorbidities that increase their risk of death require additional medical interventions to reduce mortality.
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Singh R, Dwivedi SP, Gaharwar US, Meena R, Rajamani P, Prasad T. Recent updates on drug resistance in Mycobacterium tuberculosis. J Appl Microbiol 2019; 128:1547-1567. [PMID: 31595643 DOI: 10.1111/jam.14478] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/09/2019] [Accepted: 09/13/2019] [Indexed: 12/18/2022]
Abstract
Tuberculosis (TB) along with acquired immune deficiency syndrome and malaria rank among the top three fatal infectious diseases which pose threat to global public health, especially in middle and low income countries. TB caused by Mycobacterium tuberculosis (Mtb) is an airborne infectious disease and one-third of the world's population gets infected with TB leading to nearly 1·6 million deaths annually. TB drugs are administered in different combinations of four first-line drugs (rifampicin, isoniazid, pyrazinamide and ethambutol) which form the core of treatment regimens in the initial treatment phase of 6-9 months. Several reasons account for the failure of TB therapy such as (i) late diagnosis, (ii) lack of timely and proper administration of effective drugs, (iii) lower availability of less toxic, inexpensive and effective drugs, (iv) long treatment duration, (v) nonadherence to drug regimen and (vi) evolution of drug-resistant TB strains. Drug-resistant TB poses a significant challenge to TB therapy and control programs. In the background of worldwide emergence of 558 000 new TB cases with resistance to rifampicin in the year 2017 and of them, 82% becoming multidrug-resistant TB (MDR-TB), it is essential to continuously update the knowledge on the mechanisms and molecular basis for evolution of Mtb drug resistance. This narrative and traditional review summarizes the progress on the anti-tubercular agents, their mode of action and drug resistance mechanisms in Mtb. The aim of this review is to provide recent updates on drug resistance mechanisms, newly developed/repurposed anti-TB agents in pipeline and international recommendations to manage MDR-TB. It is based on recent literature and WHO guidelines and aims to facilitate better understanding of drug resistance for effective TB therapy and clinical management.
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Affiliation(s)
- R Singh
- AIRF & Special Centre for Nano Sciences, Jawaharlal Nehru University, New Delhi, India
| | - S P Dwivedi
- IFTM University, Moradabad, Uttar Pradesh, India
| | - U S Gaharwar
- School of Environmental Sciences, Jawaharlal Nehru University, New Delhi, India
| | - R Meena
- School of Environmental Sciences, Jawaharlal Nehru University, New Delhi, India
| | - P Rajamani
- School of Environmental Sciences, Jawaharlal Nehru University, New Delhi, India
| | - T Prasad
- AIRF & Special Centre for Nano Sciences, Jawaharlal Nehru University, New Delhi, India
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Frank M, Adamashvili N, Lomtadze N, Kokhreidze E, Avaliani Z, Kempker RR, Blumberg HM. Long-term Follow-up Reveals High Posttreatment Mortality Rate Among Patients With Extensively Drug-Resistant Tuberculosis in the Country of Georgia. Open Forum Infect Dis 2019; 6:ofz152. [PMID: 31041349 PMCID: PMC6483133 DOI: 10.1093/ofid/ofz152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 03/21/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Given very limited data, we assessed the long-term outcomes among patients with extensively drug-resistant (XDR) tuberculosis (TB). METHODS A retrospective population-based cohort study was performed in patients with XDR-TB diagnosed during 2011-2013 in the country of Georgia. Data were abstracted from the National TB Program, medical charts, interviews, and the national Georgian death registry. RESULTS Among 111 patients starting treatment for XDR-TB, 59 (53.2%) had newly diagnosed tuberculosis, and 3 (2.9%) had human immunodeficiency virus (HIV) coinfection. The median length of follow-up from diagnosis of XDR-TB to death or the end of study was 53.9 months (interquartile range, 27.2-66.3 months). End-of-treatment outcomes were available for 106 patients; 35 (33.0%) had a favorable outcome, and 71 (67.0%) had an unfavorable outcome, including death in 16 (15.1%). An additional 20 patients died after cessation of initial treatment, increasing the overall mortality rate to 34.0%. In multivariable analysis, an unfavorable initial end-of-treatment outcome was associated with posttreatment death (adjusted odds ratio, 14.41; 95% confidence interval, 1.78-117.13). CONCLUSIONS The overall mortality rate and specifically the posttreatment mortality rate were high among patients with XDR-TB. Patients with an unfavorable end-of-treatment outcome had an increased risk of death during follow-up. Our findings highlight the need for improved adherence, better-tolerated and shorter therapies, and enhanced posttreatment surveillance among patients treated for XDR-TB.
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Affiliation(s)
- Melanie Frank
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Nino Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Eka Kokhreidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Kanji A, Hasan R, Hasan Z. Efflux pump as alternate mechanism for drug resistance in Mycobacterium tuberculosis. Indian J Tuberc 2019; 66:20-5. [PMID: 30797276 DOI: 10.1016/j.ijtb.2018.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/28/2018] [Accepted: 07/26/2018] [Indexed: 11/23/2022]
Abstract
Tuberculosis (TB) remains an important global public health issue with an approximate prevalence of 10 million people with TB worldwide in 2015. Since antibiotic treatment is one of the foremost tools for TB control, knowledge of Mycobacterium tuberculosis (MTB) drug resistance is an important component for disease control. Although gene mutations in specific loci of the MTB genomes are reported as the primary basis for drug resistance, additional mechanisms conferring resistance to MTB are thought to exist. Efflux is a ubiquitous mechanism responsible for innate and acquired drug resistance in prokaryotic and eukaryotic cells. MTB presents a large number of putative drug efflux pumps compared to its genome size. Bioinformatics-based evidence has shown an association between drug efflux and innate or acquired resistance in MTB. This review describes the recent understanding of drug efflux in MTB.
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Seifert M, Georghiou SB, Garfein RS, Catanzaro D, Rodwell TC. Impact of Fluoroquinolone Use on Mortality Among a Cohort of Patients With Suspected Drug-Resistant Tuberculosis. Clin Infect Dis 2018; 65:772-778. [PMID: 28475735 DOI: 10.1093/cid/cix422] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 04/28/2017] [Indexed: 11/13/2022] Open
Abstract
Background Previous retrospective and in vitro studies suggest that use of later-generation fluoroquinolones may reduce mortality risk and improve treatment outcomes for drug-resistant tuberculosis (TB) patients, including individuals resistant to a fluoroquinolone. Meta-analysis results are mixed and few studies have examined this relationship prospectively. Methods As part of a comparative diagnostic study, we conducted a prospective cohort study with 834 Mycobacterium tuberculosis-infected patients from selected hospitals and clinics with high prevalence of drug-resistant TB in India, Moldova, and South Africa. We used Cox proportional hazards regression models to assess the association between later-generation fluoroquinolone (moxifloxacin or levofloxacin) use and patient mortality, adjusting for risk factors typically associated with poor treatment outcomes. Results After adjusting for phenotypic resistance profile, low body mass index (<18.5 kg/m2), human immunodeficiency virus status, and study site, participants treated with a later-generation fluoroquinolone had half the risk of mortality compared with participants either not treated with any fluoroquinolone or treated only with an earlier-generation fluoroquinolone (adjusted hazard ratio, 0.46 [95% confidence interval, .26-.80]) during follow-up. Conclusions Use of later-generation fluoroquinolones significantly reduced patient mortality risk in our cohort, suggesting that removal of a later-generation fluoroquinolone from a treatment regimen because of demonstrated resistance to an earlier-generation fluoroquinolone might increase mortality risk. Further studies should evaluate the effectiveness of later-generation fluoroquinolones among patients with and without resistance to early-generation fluoroquinolones. Clinical Trials Registration NCT02170441.
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Affiliation(s)
- Marva Seifert
- Department of Medicine, University of California, San Diego, La Jolla
| | | | - Richard S Garfein
- Department of Medicine, University of California, San Diego, La Jolla
| | | | - Timothy C Rodwell
- Department of Medicine, University of California, San Diego, La Jolla
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Prasad R, Singh A, Balasubramanian V, Gupta N. Extensively drug-resistant tuberculosis in India: Current evidence on diagnosis & management. Indian J Med Res 2018; 145:271-293. [PMID: 28749390 PMCID: PMC5555056 DOI: 10.4103/ijmr.ijmr_177_16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Emergence of extensively drug-resistant tuberculosis (XDR-TB) has significantly threatened to jeopardize global efforts to control TB, especially in HIV endemic regions. XDR-TB is mainly an iatrogenically created issue, and understanding the epidemiological and risk factors associated with it is of paramount importance in curbing this menace. Emergence of this deadly phenomenon can be prevented by prompt diagnosis and effective treatment with second-line drugs in rifampicin-resistant TB (RR-TB) as well as multidrug-resistant TB (MDR-TB) patients. Optimal treatment of RR-TB, MDR-TB and XDR-TB cases alone will not suffice to reduce the global burden. The TB control programmes need to prioritize on policies focusing on the effective as well as rational use of first-line drugs in every newly diagnosed drug susceptible TB patients so as to prevent the emergence of drug resistance.
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Affiliation(s)
- Rajendra Prasad
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, India
| | - Abhijeet Singh
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, India
| | | | - Nikhil Gupta
- Department of Medicine, Era's Medical College, Lucknow, India
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Marfina GY, Vladimirov KB, Avetisian AO, Starshinova AA, Kudriashov GG, Sokolovich EG, Yablonskii PK. Bilateral cavitary multidrug- or extensively drug-resistant tuberculosis: role of surgery†. Eur J Cardiothorac Surg 2017; 53:618-624. [DOI: 10.1093/ejcts/ezx350] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 08/16/2017] [Indexed: 12/20/2022] Open
Affiliation(s)
- Galina Yu Marfina
- Department of Pulmonary TB Thoracic Surgery, St. Petersburg State Scientific and Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Kirill B Vladimirov
- Department of Phthisiopulmonology and Thoracic Surgery, I.I. Mechnikov’ North-West State Medical University, St. Petersburg, Russia
| | - Armen O Avetisian
- Department of Pulmonary TB Thoracic Surgery, St. Petersburg State Scientific and Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Anna A Starshinova
- Department of Pulmonary TB Thoracic Surgery, St. Petersburg State Scientific and Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Grigorii G Kudriashov
- Department of Pulmonary TB Thoracic Surgery, St. Petersburg State Scientific and Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Evgenii G Sokolovich
- Department of Pulmonary TB Thoracic Surgery, St. Petersburg State Scientific and Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Piotr K Yablonskii
- Department of Pulmonary TB Thoracic Surgery, St. Petersburg State Scientific and Research Institute of Phthisiopulmonology, St. Petersburg, Russia
- Faculty of Medicine, St. Petersburg State University, St. Petersburg, Russia
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15
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Tao NN, He XC, Zhang XX, Liu Y, Yu CB, Li HC. Trends and characteristics of drug-resistant tuberculosis in rural Shandong, China. Int J Infect Dis 2017; 65:8-14. [PMID: 28958922 DOI: 10.1016/j.ijid.2017.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 09/17/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES The aim of this study was to describe the secular trends in drug-resistant tuberculosis (DR-TB) and to identify unique characteristics of multidrug-resistant tuberculosis (MDR-TB) in rural China. METHODS A retrospective study was conducted using TB data collected from 36 TB prevention and control institutions serving rural populations in Shandong Province, China, for the period 2006-2015. RESULTS Approximately 8.3% of patients suffered from MDR-TB, among whom 70% were newly treated patients; this rate increased by 1.3% annually during the 10-year study period. An increase in the percentage of overall first-line drug resistance against isoniazid, rifampicin, ethambutol, and streptomycin was confirmed (p<0.05). The percentage of MDR-TB in new and previously treated cases increased at yearly rates of 9.9% and 11.1%, respectively. MDR-TB patients were more likely to be female (odds ratio (OR) 1.58, 95% confidence interval (CI) 1.32-1.89), smokers (OR 1.75, 95% CI 1.47-2.07), to have had recent TB contact (OR 1.58, 95% CI 1.04-2.42), or to have been retreated (OR 2.89, 95% CI 2.46-3.41). CONCLUSIONS Increasing MDR-TB and rates of primary MDR-TB characterize DR-TB cases in rural China. Persistent efforts need to be made among MDR-TB patients in future TB control strategies.
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Affiliation(s)
- Ning-Ning Tao
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xiao-Chun He
- Department of Respiratory Medicine, Baoji Central Hospital, Baoji, Shaanxi, China
| | - Xian-Xin Zhang
- Department of Respiratory Medicine, Shandong Provincial Chest Hospital, Jinan, China
| | - Yao Liu
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Chun-Bao Yu
- Katharine Hsu International Research Center of Human Infectious Diseases, Shandong Provincial Chest Hospital, Jinan, China
| | - Huai-Chen Li
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China.
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Liu F, Dawadi S, Maize KM, Dai R, Park SW, Schnappinger D, Finzel BC, Aldrich CC. Structure-Based Optimization of Pyridoxal 5'-Phosphate-Dependent Transaminase Enzyme (BioA) Inhibitors that Target Biotin Biosynthesis in Mycobacterium tuberculosis. J Med Chem 2017; 60:5507-5520. [PMID: 28594172 DOI: 10.1021/acs.jmedchem.7b00189] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The pyridoxal 5'-phosphate (PLP)-dependent transaminase BioA catalyzes the second step in the biosynthesis of biotin in Mycobacterium tuberculosis (Mtb) and is an essential enzyme for bacterial survival and persistence in vivo. A promising BioA inhibitor 6 containing an N-aryl, N'-benzoylpiperazine scaffold was previously identified by target-based whole-cell screening. Here, we explore the structure-activity relationships (SAR) through the design, synthesis, and biological evaluation of a systematic series of analogues of the original hit using a structure-based drug design strategy, which was enabled by cocrystallization of several analogues with BioA. To confirm target engagement and discern analogues with off-target activity, each compound was evaluated against wild-type (WT) Mtb in biotin-free and -containing medium as well as BioA under- and overexpressing Mtb strains. Conformationally constrained derivative 36 emerged as the most potent analogue with a KD of 76 nM against BioA and a minimum inhibitory concentration of 1.7 μM (0.6 μg/mL) against Mtb in biotin-free medium.
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Affiliation(s)
- Feng Liu
- Department of Medicinal Chemistry, University of Minnesota , Minneapolis, Minnesota 55455, United States
| | - Surendra Dawadi
- Department of Medicinal Chemistry, University of Minnesota , Minneapolis, Minnesota 55455, United States
| | - Kimberly M Maize
- Department of Medicinal Chemistry, University of Minnesota , Minneapolis, Minnesota 55455, United States
| | - Ran Dai
- Department of Medicinal Chemistry, University of Minnesota , Minneapolis, Minnesota 55455, United States
| | - Sae Woong Park
- Department of Microbiology and Immunology, Weill Cornell Medical College , New York, New York 10065, United States
| | - Dirk Schnappinger
- Department of Microbiology and Immunology, Weill Cornell Medical College , New York, New York 10065, United States
| | - Barry C Finzel
- Department of Medicinal Chemistry, University of Minnesota , Minneapolis, Minnesota 55455, United States
| | - Courtney C Aldrich
- Department of Medicinal Chemistry, University of Minnesota , Minneapolis, Minnesota 55455, United States
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Khan MA, Mehreen S, Basit A, Khan RA, Jan F, Ullah I, Ihtesham M, Khan A, Ullah U, Javaid A. Characteristics and treatment outcomes of patients with multi-drug resistant tuberculosis at a tertiary care hospital in Peshawar, Pakistan. Saudi Med J 2016; 36:1463-71. [PMID: 26620989 PMCID: PMC4707403 DOI: 10.15537/smj.2015.12.12155] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES To determine characteristics and treatment outcomes of multidrugs resistant tuberculosis (MDR-TB) patients and risk factors for poor outcomes in MDR-TB patients in a tertiary care hospital in Peshawar, Pakistan. METHODS This retrospective study was conducted at the Programmatic Management of Drug Resistant TB Unit, Lady Reading Hospital Peshawar, Pakistan and included all MDR-TB patients registered between January 2012 and December 2012. A special proforma was used for data collection. Analysis was performed using SPSS version 16, after exporting data from the proforma. Differences in proportions were assessed using Pearson's Chi square test whereas for predictors of poor outcomes, multivariate logistic regression analysis with Wald Statistical criteria using backward elimination method was performed. RESULTS The treatment success rate was 74.3%. In univariate analysis, poor outcomes were associated in patients with age ≥44 years (odds ratio [OR]=0.250; 95% confidence interval [CI]: 0.114-0.519, p=0.001), rural residence (OR=0.417; 95% CI: 0.18-0.937, p=0.03), lung cavitation (OR=0.22; 95% CI, 0.007-0.067, p=0.001), resistance to second line drugs (SLD) (OR=3.441; 95% CI: 1.579-7.497, p=0.001), and resistance to ofloxacin (OR=2.944; 95% CI: 1.361-6.365, p=0.005); whereas multivariate logistic regression analysis, poor outcomes were associated in patients with age ≥44 years (OR=0.249, 95% CI: 0.075-0.828, p=0.023), rural residence (OR=0.143, 95% CI: 0.052-0.774, p=0.032), and cavitatory lungs (OR=0.022, 95% CI: 0.007-0.072, p=0.000). CONCLUSION The MDR-TB patient needs special attention for better treatment outcomes. The presence of older age, rural area residence, resistance to ofloxacin, SLD resistance, and cavitary disease are independent prognostic factors for poor outcome in patients with MDR-TB.
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Affiliation(s)
- Mazhar A Khan
- Programmatic Management of Drug Resistant TB Unit, Lady Reading Hospital, Peshawar, Pakistan. E-mail.
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Corbetta L, Tofani A, Montinaro F, Michieletto L, Ceron L, Moroni C, Rogasi PG. Lobar Collapse Therapy Using Endobronchial Valves as a New Complementary Approach to Treat Cavities in Multidrug-Resistant Tuberculosis and Difficult-to-Treat Tuberculosis: A Case Series. Respiration 2016; 92:316-328. [DOI: 10.1159/000450757] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 09/13/2016] [Indexed: 11/19/2022] Open
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Mitnick CD, White RA, Lu C, Rodriguez CA, Bayona J, Becerra MC, Burgos M, Centis R, Cohen T, Cox H, D'Ambrosio L, Danilovitz M, Falzon D, Gelmanova IY, Gler MT, Grinsdale JA, Holtz TH, Keshavjee S, Leimane V, Menzies D, Migliori GB, Milstein MB, Mishustin SP, Pagano M, Quelapio MI, Shean K, Shin SS, Tolman AW, van der Walt ML, Van Deun A, Viiklepp P. Multidrug-resistant tuberculosis treatment failure detection depends on monitoring interval and microbiological method. Eur Respir J 2016; 48:1160-1170. [PMID: 27587552 PMCID: PMC5045442 DOI: 10.1183/13993003.00462-2016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/03/2016] [Indexed: 11/12/2022]
Abstract
Debate persists about monitoring method (culture or smear) and interval (monthly or less frequently) during treatment for multidrug-resistant tuberculosis (MDR-TB). We analysed existing data and estimated the effect of monitoring strategies on timing of failure detection. We identified studies reporting microbiological response to MDR-TB treatment and solicited individual patient data from authors. Frailty survival models were used to estimate pooled relative risk of failure detection in the last 12 months of treatment; hazard of failure using monthly culture was the reference. Data were obtained for 5410 patients across 12 observational studies. During the last 12 months of treatment, failure detection occurred in a median of 3 months by monthly culture; failure detection was delayed by 2, 7, and 9 months relying on bimonthly culture, monthly smear and bimonthly smear, respectively. Risk (95% CI) of failure detection delay resulting from monthly smear relative to culture is 0.38 (0.34–0.42) for all patients and 0.33 (0.25–0.42) for HIV-co-infected patients. Failure detection is delayed by reducing the sensitivity and frequency of the monitoring method. Monthly monitoring of sputum cultures from patients receiving MDR-TB treatment is recommended. Expanded laboratory capacity is needed for high-quality culture, and for smear microscopy and rapid molecular tests. Monthly culture monitoring is crucial to earlier detection of treatment failure in MDR-TB patientshttp://ow.ly/w2MI301mK8M
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Affiliation(s)
- Carole D Mitnick
- Dept of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA Partners in Health, Boston, MA, USA
| | - Richard A White
- Dept of Infectious Disease Epidemiology, Norwegian Institute of Public Health, Oslo, Norway Dept of Health Statistics, Norwegian Institute of Public Health, Oslo, Norway
| | - Chunling Lu
- Dept of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA Brigham and Women's Hospital, Division of Global Health Equity, Boston, MA, USA
| | - Carly A Rodriguez
- Dept of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Mercedes C Becerra
- Dept of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA Partners in Health, Boston, MA, USA Brigham and Women's Hospital, Division of Global Health Equity, Boston, MA, USA
| | - Marcos Burgos
- Dept of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Rosella Centis
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Theodore Cohen
- Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Helen Cox
- Médecins Sans Frontières, Cape Town, South Africa
| | - Lia D'Ambrosio
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy Public Health Consulting Group, Lugano, Switzerland
| | | | - Dennis Falzon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | | | | | - Jennifer A Grinsdale
- Tuberculosis Control, San Francisco Department of Public Health, San Francisco, CA, USA
| | - Timothy H Holtz
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Salmaan Keshavjee
- Dept of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA Partners in Health, Boston, MA, USA Brigham and Women's Hospital, Division of Global Health Equity, Boston, MA, USA
| | - Vaira Leimane
- State Agency for Tuberculosis and Lung Diseases (TPSVA), Riga, Latvia
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Meredith B Milstein
- Dept of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | | | - Marcello Pagano
- Dept of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| | - Maria I Quelapio
- Tropical Disease Foundation, Philippine Institute of Tuberculosis, Makati City, Philippines
| | - Karen Shean
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sonya S Shin
- Dept of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA Partners in Health, Boston, MA, USA Brigham and Women's Hospital, Division of Global Health Equity, Boston, MA, USA Socios en Salud Sucursal, Lima, Peru
| | - Arielle W Tolman
- Dept of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Martha L van der Walt
- South African Medical Research Council, Tuberculosis Research Platform, Pretoria, South Africa
| | | | - Piret Viiklepp
- National Institute for Heath Development, Tallinn, Estonia
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Elmi OS, Hasan H, Abdullah S, Mat Jeab MZ, Ba Z, Naing NN. Treatment Outcomes of Patients with Multidrug-Resistant Tuberculosis (MDR- TB) Compared with Non-MDR-TB Infections in Peninsular Malaysia. Malays J Med Sci 2016; 23:17-25. [PMID: 27660541 DOI: 10.21315/mjms2016.23.4.3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 06/01/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Treating patients with multidrug-resistant tuberculosis (MDR-TB) strains is more complicated, complex, toxic, expensive, than treating patients with susceptible TB strains. This study aims to compare the treatment outcomes and potential factors associated between patients with MDR-TB and non MDR TB infections in peninsular Malaysia. METHODS This study was a retrospective cohort study. Data were collected from the medical records of all registered MDR-TB patients and Non-MDR-TB patients at five TB hospitals in peninsular Malaysia from January 2010 to January 2014. RESULTS A total of 314 subjects were studied, including 105 MDR-TB cases and 209 non-MDR-TB. After TB treatment, 24.8% of the MDR-TB patients and 17.7% of non MDR TB relapsed; 17.1% of the MDR-TB patients and 16.3% of non MDR TB defaulted from TB treatment. A significant difference seen in treatment success rate 17.1% for MDR-TB; 63.1% for non MDR TB (P < 0.001)). Mortality rate were 8.9% for MDR-TB; 13.2% for non MDR TB. Multivariable analysis showed the potential factors associated with poor treatment outcomes were presence of HIV infection (AOR, 1.09; 95%CI: 1.05, 1.75; P = 0.001) and previous TB treatment (AOR, 4.87; 95%CI: 2.84, 8.38; P = 0.001). CONCLUSION This study revealed that the treatment success rate in patients with non MDR TB infection was higher than MDR-TB. Unsuccessful treatment was seen in MDR-TB associated with potential factors such as history of TB treatment, and presence of HIV infection.
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Affiliation(s)
- Omar Salad Elmi
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Health Campus 16150, Kubang Kerian, Kelantan, Malaysia
| | - Habsah Hasan
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Health Campus 16150, Kubang Kerian, Kelantan, Malaysia
| | - Sarimah Abdullah
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Health Campus 16150, Kubang Kerian, Kelantan, Malaysia
| | - Mat Zuki Mat Jeab
- Respiratory Unit, Department of Medicine, Hospital Raja Perempuan Zainab II Kota Bharu, Kelantan, Malaysia
| | - Zilfalil Ba
- Department of Pediatrics, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150, Kubang Kerian, Kelantan, Malaysia
| | - Nyi Nyi Naing
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Health Campus 16150, Kubang Kerian, Kelantan, Malaysia
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Musteikienė G, Miliauskas S, Sakalauskas R, Vitkauskienė A, Žemaitis M. Multidrug-resistant tuberculosis in Lithuania - Still a long way ahead. Medicina (Kaunas) 2016; 52:69-78. [PMID: 27170479 DOI: 10.1016/j.medici.2016.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 02/01/2016] [Accepted: 02/13/2016] [Indexed: 11/21/2022]
Abstract
Despite the recent advances in the diagnosis of tuberculosis, treatment of the disease, for the most part, remains the same as it was half a century ago. In recent years only two new anti-tuberculosis drugs have been approved by the European Medicines Agency and Food and Drug Administration. Though the prevalence of this disease is slowly decreasing all over Europe, new challenges appear. One of them is multidrug-resistant tuberculosis (MDR-TB). This problem is especially prominent in Lithuania, which is one of the 27 high MDR-TB burden countries in the world and falls behind neighboring countries in terms of the prevalence of the disease. The objective of this paper was to review the situation of tuberculosis and MDR-TB in Lithuania, and current available methods of treatment, control and diagnosis of this disease.
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Sotgiu G, D'Ambrosio L, Centis R, Mura I, Castiglia P, Spanevello A, Migliori GB. The multidrug-resistant tuberculosis threat: old problems and new solutions. J Thorac Dis 2015; 7:E354-60. [PMID: 26543630 DOI: 10.3978/j.issn.2072-1439.2015.09.21] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Giovanni Sotgiu
- 1 Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari - Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy ; 2 Public Health Consulting Group, Lugano, Switzerland ; 3 World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy ; 4 Respiratory Medicine, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Lia D'Ambrosio
- 1 Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari - Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy ; 2 Public Health Consulting Group, Lugano, Switzerland ; 3 World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy ; 4 Respiratory Medicine, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Rosella Centis
- 1 Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari - Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy ; 2 Public Health Consulting Group, Lugano, Switzerland ; 3 World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy ; 4 Respiratory Medicine, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Ida Mura
- 1 Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari - Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy ; 2 Public Health Consulting Group, Lugano, Switzerland ; 3 World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy ; 4 Respiratory Medicine, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Paolo Castiglia
- 1 Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari - Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy ; 2 Public Health Consulting Group, Lugano, Switzerland ; 3 World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy ; 4 Respiratory Medicine, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Antonio Spanevello
- 1 Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari - Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy ; 2 Public Health Consulting Group, Lugano, Switzerland ; 3 World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy ; 4 Respiratory Medicine, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Giovanni Battista Migliori
- 1 Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari - Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy ; 2 Public Health Consulting Group, Lugano, Switzerland ; 3 World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy ; 4 Respiratory Medicine, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
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El Kamel A, Joobeur S, Skhiri N, Cheikh Mhamed S, Mribah H, Rouatbi N. [Fight against tuberculosis in the world]. Rev Pneumol Clin 2015; 71:181-187. [PMID: 24878188 DOI: 10.1016/j.pneumo.2014.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 03/24/2014] [Accepted: 03/26/2014] [Indexed: 06/03/2023]
Abstract
Tuberculosis (TB) in a major health problem in the world. WHO and its partners especially, the stop TB partnership launched numerous strategies against TB especially in the 1990. Strategy DOTS (directly observed therapy short course) was launched in 1995. One main key was the direct supervision of drug intake by patients. Progress was achieved but it was insufficient. A new strategy called "Stop TB Strategy 2006-2015" was launched in 2006 in the context of Millennium Development Goals (MDG) elaborated by United Nations. The common goals were to halt and start to reverse the incidence of TB, reduce the prevalence and death rate by 50% compared to their level in 1990 by 2015 to eliminate TB as a public health problem by 2050. The end of 2010 marks the mid-point of the Global Plan and is an obvious time to update it and take into account actual progress with a focus on the 2015 to reach goals. So an updated Global Plan to stop TB 2011-2015, was launched. Expected progress and targets were defined for 2015, in diagnosis and treatment, in co-infection TB/HIV, in drug-resistant TB and achievements expected in new tests for diagnosis, new medications, new vaccines and new regimens with shorter duration of treatment. WHO and partners have started discussions to define the new post 2015 strategy to TB control and elimination. Risk factors (diabetes, malnutrition, tobacco smoke…) and socioeconomic factors, which are associated with TB, should be included in the new strategy to eliminate TB in 2050.
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Affiliation(s)
- A El Kamel
- Service de pneumologie, hôpital universitaire F. Bourguiba, rue 1(er)-juin-1955, 5000 Monastir, Tunisie.
| | - S Joobeur
- Service de pneumologie, hôpital universitaire F. Bourguiba, rue 1(er)-juin-1955, 5000 Monastir, Tunisie
| | - N Skhiri
- Service de pneumologie, hôpital universitaire F. Bourguiba, rue 1(er)-juin-1955, 5000 Monastir, Tunisie
| | - S Cheikh Mhamed
- Service de pneumologie, hôpital universitaire F. Bourguiba, rue 1(er)-juin-1955, 5000 Monastir, Tunisie
| | - H Mribah
- Service de pneumologie, hôpital universitaire F. Bourguiba, rue 1(er)-juin-1955, 5000 Monastir, Tunisie
| | - N Rouatbi
- Service de pneumologie, hôpital universitaire F. Bourguiba, rue 1(er)-juin-1955, 5000 Monastir, Tunisie
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Tritar F, Daghfous H, Ben Saad S, Slim-Saidi L. [Management of multidrug-resistant tuberculosis]. Rev Pneumol Clin 2015; 71:130-139. [PMID: 25153927 DOI: 10.1016/j.pneumo.2014.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 05/10/2014] [Accepted: 05/15/2014] [Indexed: 06/03/2023]
Abstract
The emergence of drug-resistant TB in many countries has become a major public health problem and an obstacle to effective tuberculosis control. Multidrug-resistant tuberculosis (MDR-TB), which is most often the result of poor adherence, is a particularly dangerous form of tuberculosis because it is caused by bacilli resistant to at least isoniazid and rifampicin, the two most effective anti-tuberculosis drugs. Techniques for rapid diagnosis of resistance have greatly improved the care of patients by allowing early treatment which remains complex and costly establishment, and requires skills and resources. The treatment is not standardized but it includes in all cases attack phase with five drugs (there must be an injectable agent and a fluoroquinolone that form the basis of the regimen) for eight months and a maintenance phase (without injectable agent) with a total duration of 20 months on average. Surgery may be beneficial as long as the lesions are localized and the patient has a good cardiorespiratory function. Evolution of MDR-TB treated is less favorable than tuberculosis with germ sensitive. The cure rate varies from 60 to 75% for MDR-TB, and drops to 30 to 40% for XDR-TB. Mortality remains high, ranging from 20 to 40% even up to 70-90% in people co-infected with HIV.
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Affiliation(s)
- F Tritar
- Service de pneumologie, hôpital A.-Mami, Ariana, 2080 Tunis, Tunisie.
| | - H Daghfous
- Service de pneumologie, hôpital A.-Mami, Ariana, 2080 Tunis, Tunisie
| | - S Ben Saad
- Service de pneumologie, hôpital A.-Mami, Ariana, 2080 Tunis, Tunisie
| | - L Slim-Saidi
- Service de bactériologie, hôpital A.-Mami, Ariana, 2080 Tunis, Tunisie
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Parida SK, Axelsson-Robertson R, Rao MV, Singh N, Master I, Lutckii A, Keshavjee S, Andersson J, Zumla A, Maeurer M. Totally drug-resistant tuberculosis and adjunct therapies. J Intern Med 2015; 277:388-405. [PMID: 24809736 DOI: 10.1111/joim.12264] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The first cases of totally drug-resistant (TDR) tuberculosis (TB) were reported in Italy 10 years ago; more recently, cases have also been reported in Iran, India and South Africa. Although there is no consensus on terminology, it is most commonly described as 'resistance to all first- and second-line drugs used to treat TB'. Mycobacterium tuberculosis (M.tb) acquires drug resistance mutations in a sequential fashion under suboptimal drug pressure due to monotherapy, inadequate dosing, treatment interruptions and drug interactions. The treatment of TDR-TB includes antibiotics with disputed or minimal effectiveness against M.tb, and the fatality rate is high. Comorbidities such as diabetes and infection with human immunodeficiency virus further impact on TB treatment options and survival rates. Several new drug candidates with novel modes of action are under late-stage clinical evaluation (e.g., delamanid, bedaquiline, SQ109 and sutezolid). 'Repurposed' antibiotics have also recently been included in the treatment of extensively drug resistant TB. However, because of mutations in M.tb, drugs will not provide a cure for TB in the long term. Adjunct TB therapies, including therapeutic vaccines, vitamin supplementation and/or repurposing of drugs targeting biologically and clinically relevant molecular pathways, may achieve better clinical outcomes in combination with standard chemotherapy. Here, we review broader perspectives of drug resistance in TB and potential adjunct treatment options.
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Affiliation(s)
- S K Parida
- Therapeutic Immunology Division, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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Abstract
Emergence of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB over the past decade presents an unprecedented public health challenge to which countries of concern are responding far too slowly. Global Tuberculosis Report 2014 marks the 20th anniversary of the Global Project on Anti-Tuberculosis Drug Resistance Surveillance, indicating the highest global level of drug-resistance ever recorded detection of 97 000 patients with MDR-TB resulting in 170 000 deaths in 2013. Treatment of MDR-TB is expensive, complex, prolonged (18-24 months) and associated with a higher incidence of adverse events. In this context, nanocarrier delivery systems (NDSs) efficiently encapsulating considerable amounts of second-line anti tubercular drugs ((s)ATDs), eliciting controlled, sustained and more profound effect to trounce the need to administer (s)ATDs at high and frequent doses, would assist in improving patient compliance and avoid hepatotoxicity and/or nephrotoxicity/ocular toxicity/ototoxicity associated with the prevalent (s)ATDs. Besides, NDSs are also known to inhibit the P-glycoprotein efflux, reduce metabolism by gut cytochrome P-450 enzymes and circumnavigate the hepatic first-pass effect, facilitating absorption of drugs via intestinal lymphatic pathways. This review first provides a holistic account on MDR-TB and discusses the molecular basis of Mycobacterium tuberculosis resistance to anti-tubercular drugs. It also provides an updated bird's eye view on current treatment strategies and laboratory diagnostic test for MDR-TB. Furthermore, a relatively pithy view on patent studies on second-line chemotherapy using NDSs will be discussed.
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Affiliation(s)
- Sanaul Mustafa
- Department of Pharmaceutics, Al-Ameen College of Pharmacy , Bangalore, Karnataka , India
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Lee YS, Kang MR, Jung H, Choi SB, Jo KW, Shim TS. Performance of REBA MTB-XDR to detect extensively drug-resistant tuberculosis in an intermediate-burden country. J Infect Chemother 2015; 21:346-51. [PMID: 25634305 DOI: 10.1016/j.jiac.2014.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 12/19/2014] [Accepted: 12/24/2014] [Indexed: 10/24/2022]
Abstract
Extensively drug-resistant tuberculosis (XDR-TB) is a serious worldwide problem. The REBA MTB-XDR (REBA-XDR) was recently developed in Korea to detect resistance to ofloxacin, kanamycin, and streptomycin. The aim of this study is to evaluate the diagnostic accuracy of the REBA-XDR. We prospectively enrolled 104 patients with acid-fast bacilli smear-positive specimens between July 2010 and January 2013. Performance characteristics were compared between REBA-XDR and conventional drug-susceptibility testing. The sensitivity values of REBA-XDR for detecting resistance to ofloxacin, kanamycin, and streptomycin were 66.7%, 90.9%, and 60.0%, and the specificity values were 93.3%, 93.5%, and 85.4%, respectively. The positive predictive values were 62.5%, 62.5%, and 40.9%, and the negative predictive values were 94.3%, 98.9%, and 92.7%, respectively. Accuracy was 89.4%, 93.3%, and 81.7%, respectively. REBA-XDR seems to be a useful kit for "ruling in" XDR-TB in intermediate-burden countries, and especially useful for detecting kanamycin resistance.
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Affiliation(s)
- Young Seok Lee
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | | | - Hoon Jung
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Sang Bong Choi
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Kyung-Wook Jo
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Tae Sun Shim
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
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Confalonieri M, Cifaldi R, Longo C, Amadio G, Santagiuliana M, Maurel C, Jevnikar M, Luzzati R. Epidemiology of Tuberculosis and the Rise of XDR-TB. Curr Treat Options Infect Dis 2014; 6:353-76. [DOI: 10.1007/s40506-014-0035-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Bastos ML, Hussain H, Weyer K, Garcia-Garcia L, Leimane V, Leung CC, Narita M, Penã JM, Ponce-de-Leon A, Seung KJ, Shean K, Sifuentes-Osornio J, Van der Walt M, Van der Werf TS, Yew WW, Menzies D. Treatment outcomes of patients with multidrug-resistant and extensively drug-resistant tuberculosis according to drug susceptibility testing to first- and second-line drugs: an individual patient data meta-analysis. Clin Infect Dis 2014; 59:1364-74. [PMID: 25097082 DOI: 10.1093/cid/ciu619] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Individualized treatment for multidrug-resistant (MDR) tuberculosis and extensively drug-resistant (XDR) tuberculosis depends upon reliable and valid drug susceptibility testing (DST) for pyrazinamide, ethambutol, and second-line tuberculosis drugs. However, the reliability of these tests is uncertain, due to unresolved methodological issues. We estimated the association of DST results for pyrazinamide, ethambutol, and second-line drugs with treatment outcomes in patients with MDR tuberculosis and XDR tuberculosis. METHODS We conducted an analysis of individual patient data assembled from 31 previously published cohort studies of patients with MDR and XDR tuberculosis. We used data on patients' clinical characteristics including DST results, treatment received, outcomes, and laboratory methods in each center. RESULTS DST methods and treatment regimens used in different centers varied considerably. Among 8955 analyzed patients, in vitro susceptibility to individual drugs was consistently and significantly associated with higher odds of treatment success (compared with resistance to the drug), if that drug was used in the treatment regimen. Various adjusted and sensitivity analyses suggest that this was not explained by confounding. The adjusted odds of treatment success for ethambutol, pyrazinamide, and the group 4 drugs ranged from 1.7 to 2.3, whereas for second-line injectables and fluoroquinolones, odds ranged from 2.4 to 4.6. CONCLUSIONS DST for ethambutol, pyrazinamide, and second-line tuberculosis drugs appears to provide clinically useful information to guide selection of treatment regimens for MDR and XDR tuberculosis.
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Abstract
Multi-drug resistant tuberculosis (MDR-TB) is caused by Mycobacterium tuberculosis strains resistant to at least two of the most effective anti-tuberculosis drugs (i.e., isoniazid and rifampicin). Therapeutic regimens based on second- and third-line anti-tuberculosis medicines showed poor efficacy, safety, and tolerability profiles. It was estimated that in 2012 the multi-drug resistant tuberculosis incidence ranged from 300,000 to 600,000 cases, mainly diagnosed in the Eastern European and Central Asian countries. The highest proportion of cases is among individuals previously exposed to anti-tuberculosis drugs. Three main conditions can favour the emergence and spread of multi-drug resistant tuberculosis: the poor implementation of the DOTS strategy, the shortage or the poor quality of the anti-tuberculosis drugs, and the poor therapeutic adherence of the patients to the prescribed regimens. Consultation with tuberculosis experts (e.g., consilium) is crucial to tailor the best anti-tuberculosis therapy. New therapeutic options are necessary: bedaquiline and delamanid seem promising drugs; in particular, during the development phase they demonstrated a protective effect against the emergence of further resistances towards the backbone drugs. In the recent past, other antibiotics have been administered off-label: the most relevant efficacy, safety, and tolerability profile was proved in linezolid-, meropenem/clavulanate-, cotrimoxazole-containing regimens. New research and development activities are needed in the diagnostic, therapeutic, preventive fields.
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Affiliation(s)
- Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy
| | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, via Roncaccio 16, 21049 Tradate (VA), Italy.
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31
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Abstract
The advent of antibiotics for the treatment of tuberculosis (TB) represented a major breakthrough in the fight against the disease. However, since its first use, antibiotic therapy has been associated with the emergence of resistance to drugs. The incorrect use of anti-TB drugs, either due to prescription errors, low patient compliance, or poor quality of drugs, led to the widespread emergence of Mycobacterium tuberculosis strains with an expanding spectrum of resistance. The spread of multidrug-resistant (MDR) strains (ie, strains resistant to both isoniazid and rifampicin) has represented a major threat to TB control since the 1990s. In 2006, the first cases of MDR strains with further resistance to fluoroquinolone and injectable drugs were described and named extensively drug-resistant TB (XDR-TB). The emergence of XDR-TB strains is a result of mismanagement of MDR cases, and treatment relies on drugs that are less potent and more toxic than those used to treat drug-susceptible or MDR strains. Furthermore, treatment success is lower and mortality higher than achieved in MDR-TB cases, and the number of drugs necessary in the intensive phase of treatment may be higher than the four drugs recommended for MDR-TB. Linezolid may represent a valuable drug to treat cases of XDR-TB. Delamanid, bedaquiline, and PA-824 are new anti-TB agents in the development pipeline that have the potential to enhance the cure rate of XDR-TB. The best measures to prevent new cases of XDR-TB are the correct management of MDR-TB patients, early detection, and proper treatment of existing patients with XDR-TB.
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Affiliation(s)
- Alberto Matteelli
- Institute of Infectious and Tropical Diseases, WHO Collaborating Centre for TB/HIV Co-Infection, University of Brescia, Brescia, Italy
| | - Alberto Roggi
- Institute of Infectious and Tropical Diseases, WHO Collaborating Centre for TB/HIV Co-Infection, University of Brescia, Brescia, Italy
| | - Anna CC Carvalho
- Laboratory of Innovations in Therapies, Education and Bioproducts (LITEB), Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
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Dheda K, Gumbo T, Gandhi NR, Murray M, Theron G, Udwadia Z, Migliori GB, Warren R. Global control of tuberculosis: from extensively drug-resistant to untreatable tuberculosis. Lancet Respir Med 2014; 2:321-38. [PMID: 24717628 DOI: 10.1016/s2213-2600(14)70031-1] [Citation(s) in RCA: 199] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Extensively drug-resistant tuberculosis is a burgeoning global health crisis mainly affecting economically active young adults, and has high mortality irrespective of HIV status. In some countries such as South Africa, drug-resistant tuberculosis represents less than 3% of all cases but consumes more than a third of the total national budget for tuberculosis, which is unsustainable and threatens to destabilise national tuberculosis programmes. However, concern about drug-resistant tuberculosis has been eclipsed by that of totally and extremely drug-resistant tuberculosis--ie, resistance to all or nearly all conventional first-line and second-line antituberculosis drugs. In this Review, we discuss the epidemiology, pathogenesis, diagnosis, management, implications for health-care workers, and ethical and medicolegal aspects of extensively drug-resistant tuberculosis and other resistant strains. Finally, we discuss the emerging problem of functionally untreatable tuberculosis, and the issues and challenges that it poses to public health and clinical practice. The emergence and growth of highly resistant strains of tuberculosis make the development of new drugs and rapid diagnostics for tuberculosis--and increased funding to strengthen global control efforts, research, and advocacy--even more pressing.
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Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
| | - Tawanda Gumbo
- Office of Global Health and Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Neel R Gandhi
- Departments of Epidemiology, Global Health, and Infectious Diseases, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Megan Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Grant Theron
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - G B Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S Maugeri, Care and Research Institute, Tradate, Italy
| | - Robin Warren
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, MRC Centre for Molecular and Cellular Biology, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Abstract
For the successful treatment of pulmonary tuberculosis, drugs need to penetrate complex lung lesions and permeate the mycobacterial cell wall in order to reach their intracellular targets. However, most currently used anti-tuberculosis drugs were introduced into clinical use without considering the pharmacokinetic and pharmacodynamic properties that influence drug distribution, and this has contributed to the long duration and limited success of current therapies. In this Progress article, I describe new methods to quantify and image drug distribution in infected lung tissue and in mycobacterial cells, and I explore how this technology could be used to design optimized multidrug regimens.
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Banerjee R, Schecter GF, Flood J, Porco TC. Extensively drug-resistant tuberculosis: new strains, new challenges. Expert Rev Anti Infect Ther 2014; 6:713-24. [DOI: 10.1586/14787210.6.5.713] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Flor de Lima B, Tavares M. Risk factors for extensively drug-resistant tuberculosis: a review. Clin Respir J 2013; 8:11-23. [PMID: 23875862 DOI: 10.1111/crj.12044] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 07/09/2013] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Extensively drug-resistant tuberculosis (XDR-TB) is emerging as a global public health problem. Its treatment is more expensive and difficult, and the outcomes much severe. The identification of risk factors for XDR-TB is of paramount importance to design effective TB control strategies. OBJECTIVE To review published articles on risk factors for XDR-TB. METHODS We identified 249 English articles on PubMed, and 182 were excluded by the abstract. The remaining articles were retrieved for full-text detailed evaluation by authors, and 27 relevant articles were selected for final review. RESULTS Some risk factors were consistently present, mainly previous TB treatment and its length. Other conditions often associated were immigration, alcoholism and HIV coinfection. Pre-XDR-TB points to an increased risk of XDR-TB. CONCLUSION The information regarding determinants of XDR-TB is relatively weak. However, special emphasis should be given to minimize the risks of TB retreatment to prevent the emergence of highly resistant TB.
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Affiliation(s)
- Bárbara Flor de Lima
- Master Programme in Medicine, Hospital de São João and University of Porto Medical School, Portugal
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36
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Shah NS, Yuen CM, Heo M, Tolman AW, Becerra MC. Yield of contact investigations in households of patients with drug-resistant tuberculosis: systematic review and meta-analysis. Clin Infect Dis 2013; 58:381-91. [PMID: 24065336 DOI: 10.1093/cid/cit643] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Contact investigations among individuals living with drug-susceptible tuberculosis patients (source cases) have shown a high yield of tuberculosis disease and latent tuberculosis, but the yield of such investigations in households of drug-resistant tuberculosis source cases is unknown. In this systematic review and meta-analysis, we found 25 studies that evaluated a median of 111 (interquartile range, 21-302) household contacts of drug-resistant tuberculosis source cases. The pooled yield was 7.8% (95% CI, 5.6%-10.0%) for active tuberculosis and 47.2% (95% CI, 30.0%-61.4%) for latent tuberculosis, although there was significant statistical heterogeneity (P < .0001). More than 50% of secondary cases with drug susceptibility test results were concordant with those of the source case. Among studies that followed household members, the majority of secondary cases were detected within 1 year of the source case's diagnosis. Household contact investigation around drug-resistant tuberculosis patients is a high-yield intervention for detection of drug-resistant tuberculosis and prevention of ongoing transmission.
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Affiliation(s)
- N Sarita Shah
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
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37
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Sotgiu G, Centis R, D’ambrosio L, Tadolini M, Castiglia P, Migliori GB. Do we need a new Fleming époque: The nightmare of drug-resistant tuberculosis. Int J Mycobacteriol 2013; 2:123-5. [DOI: 10.1016/j.ijmyco.2013.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 07/01/2013] [Indexed: 11/16/2022] Open
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Jiang RH, Xu HB, Li L. Comparative roles of moxifloxacin and levofloxacin in the treatment of pulmonary multidrug-resistant tuberculosis: a retrospective study. Int J Antimicrob Agents 2013; 42:36-41. [DOI: 10.1016/j.ijantimicag.2013.02.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 02/04/2013] [Accepted: 02/11/2013] [Indexed: 11/24/2022]
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Abstract
Multidrug-resistant (MDR) tuberculosis (TB) denotes bacillary resistance to at least isoniazid and rifampicin. Extensively drug-resistant (XDR) TB is MDR-TB with additional bacillary resistance to any fluoroquinolone and at least one second-line injectable drugs. Rooted in inadequate TB treatment and compounded by a vicious circle of diagnostic delay and improper treatment, MDR-TB/XDR-TB has become a global epidemic that is fuelled by poverty, human immunodeficiency virus (HIV) and neglect of airborne infection control. The majority of MDR-TB cases in some settings with high prevalence of MDR-TB are due to transmission of drug-resistant bacillary strains to previously untreated patients. Global efforts in controlling MDR-TB/XDR-TB can no longer focus solely on high-risk patients. It is difficult and costly to treat MDR-TB/XDR-TB. Without timely implementation of preventive and management strategies, difficult MDR-TB/XDR-TB can cripple global TB control efforts. Preventive strategies include prompt diagnosis with adequate TB treatment using the directly observed therapy, short-course (DOTS) strategy and drug-resistance programmes, airborne infection control, preventive treatment of TB/HIV, and optimal use of antiretroviral therapy. Management strategies for established cases of difficult MDR-TB/XDR-TB rely on harnessing existing drugs (notably newer generation fluoroquinolones, high-dose isoniazid, linezolid and pyrazinamide with in vitro activity) in the best combinations and dosing schedules, together with adjunctive surgery in carefully selected cases. Immunotherapy may also have a role in the future. New diagnostics, drugs and vaccines are required to meet the challenge, but science alone is insufficient. Difficult MDR-TB/XDR-TB cannot be tackled without achieving high cure rates with quality DOTS and beyond, and concurrently addressing poverty and HIV.
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Affiliation(s)
- Kwok-Chiu Chang
- Department of Health, Tuberculosis and Chest Service, the Chinese University of Hong Kong, Hong Kong, China.
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40
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Chang KC, Yew WW, Tam CM, Leung CC. WHO group 5 drugs and difficult multidrug-resistant tuberculosis: a systematic review with cohort analysis and meta-analysis. Antimicrob Agents Chemother 2013; 57:4097-104. [PMID: 23774431 DOI: 10.1128/AAC.00120-13] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
It is often necessary to include WHO group 5 drugs in the treatment of extensively drug-resistant tuberculosis (XDR-TB) and fluoroquinolone-resistant multidrug-resistant tuberculosis (MDR-TB). As clinical evidence about the use of group 5 drugs is scarce, we conducted a systematic review using published individual patient data. We searched PubMed and OvidSP through 7 April 2013 for publications in English to assemble a cohort with fluoroquinolone-resistant MDR-TB treated with group 5 drugs. Favorable outcome was defined as sputum culture conversion, cure, or treatment completion in the absence of death, default, treatment failure, or relapse. A cohort of 194 patients was assembled from 20 articles involving 12 geographical regions. In descending order of frequency, linezolid was used in treatment of 162 (84%) patients, macrolides in 84 (43%), clofazimine in 65 (34%), amoxicillin with clavulanate in 56 (29%), thioridazine in 18 (9%), carbapenem in 16 (8%), and high-dose isoniazid in 16 (8%). Cohort analysis with robust Poisson regression models and random-effects meta-analysis similarly suggested that linezolid use significantly increased the probability (95% confidence interval) of favorable outcome by 57% (10% to 124%) and 55% (10% to 121%), respectively. Defining significant associations by risk ratios ≥ 1.2 or ≤ 0.9, neither cohort analysis nor meta-analysis demonstrated any significant add-on benefit from the use of other group 5 drugs with respect to outcome for patients treated with linezolid, although selection bias might have led to underestimation of their effects. Our findings substantiated the use of linezolid in the treatment of XDR-TB or fluoroquinolone-resistant MDR-TB and call for further studies to evaluate the roles of other group 5 drugs.
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Kang YA, Kim SY, Jo KW, Kim HJ, Park SK, Kim TH, Kim EK, Lee KM, Lee SS, Park JS, Koh WJ, Kim DY, Shim TS. Impact of diabetes on treatment outcomes and long-term survival in multidrug-resistant tuberculosis. ACTA ACUST UNITED AC 2013; 86:472-8. [PMID: 23689646 DOI: 10.1159/000348374] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 01/24/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Few studies have investigated the impact of diabetes mellitus (DM), a globally increasing metabolic disease, on treatment outcomes and long-term survival in patients with multidrug-resistant forms of tuberculosis (MDR-TB). OBJECTIVES We analyzed outcomes in a large cohort to assess the impact of DM on treatment outcomes of patients with MDR-TB. METHODS MDR-TB patients newly diagnosed or retreated between 2000 and 2002 and followed for 8-11 years were retrospectively analyzed with respect to the effect of DM as a comorbidity on their treatment outcome and long-term survival. RESULTS Of 1,407 patients with MDR-TB, 239 (17.0%) had coexisting DM. The mean age and body mass index were higher in MDR-TB patients with DM [MDR-TBDM(+)] than in those without DM [MDR-TBDM(-)]. Patients with MDR-TB and a comorbidity of DM had a significantly lower treatment success rate than those without a history of DM (36.0 vs. 47.2%, p = 0.002). In addition, DM was the negative predictor for MDR-TB treatment success in multivariate analyses [odds ratio 0.51, 95% confidence interval (CI) 0.26-0.99]. Mean survival times were also lower in MDR-TBDM(+) than in MDR-TBDM(-) patients (102 vs. 114 months, p = 0.001), with DM as a significant predictor of poor long-term survival in multivariate analyses (hazard ratio 1.59, 95% CI 1.01-2.50). CONCLUSIONS Among MDR-TB patients, DM was a relatively common comorbidity. In patients undergoing treatment for MDR-TB and followed for 8-11 years, it was found to be independently associated with an increased risk of both treatment failure and death.
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Affiliation(s)
- Young Ae Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
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Cegielski P, Nunn P, Kurbatova EV, Weyer K, Dalton TL, Wares DF, Iademarco MF, Castro KG, Raviglione M. Challenges and controversies in defining totally drug-resistant tuberculosis. Emerg Infect Dis 2013; 18:e2. [PMID: 23092736 PMCID: PMC3559144 DOI: 10.3201/eid1811.120526] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
In March 2012, in response to reports of tuberculosis (TB) resistant to all anti-TB drugs, the World Health Organization convened an expert consultation that identified issues to be resolved before defining a new category of highly drug-resistant TB. Proposed definitions are ambiguous, and extensive drug resistance is encompassed by the already defined extensively drug-resistant (XDR) TB. There is no evidence that proposed totally resistant TB differs from strains encompassed by XDR TB. Susceptibility tests for several drugs are poorly reproducible. Few laboratories can test all drugs, and there is no consensus list of all anti-TB drugs. Many drugs are used off-label for highly drug resistant TB, and new drugs formulated to combat resistant strains would render the proposed category obsolete. Labeling TB strains as totally drug resistant might lead providers to think infected patients are untreatable. These challenges must be addressed before defining a new category for highly drug-resistant TB.
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Affiliation(s)
- Peter Cegielski
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Chang KC, Yew WW, Zhang Y. A systematic review of rapid drug susceptibility tests for multidrug-resistant tuberculosis using rifampin resistance as a surrogate. ACTA ACUST UNITED AC 2013; 3:99-122. [PMID: 23485158 DOI: 10.1517/17530050802665694] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The emergence of multidrug-resistant tuberculosis (MDR-TB) has prompted the development of rapid drug susceptibility assays with a focus on rifampin in recent years. Systematic reviews with evaluation of predictive values for different assays are scarce. METHOD MEDLINE was searched on 6 September 2008 for English articles that contain concurrent original data for generating summary measures of sensitivity, specificity and likelihood ratios of rapid rifampin susceptibility assays. RESULTS/CONCLUSIONS Significant heterogeneity was found in likelihood ratios across studies of all assays except nitrate reductase assay and colorimetric assays. Although rapid assays are fairly reliable for ruling out MDR-TB, careful consideration of clinical risk factors is required before using these assays to rule in MDR-TB under different epidemiological settings.
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Affiliation(s)
- Kwok-Chiu Chang
- Senior Medical and Health Officer Tuberculosis and Chest Service, Wanchai Chest Clinic, Department of Health, 1st Floor, Wanchai Polyclinic, 99, Kennedy Road, Wanchai, Hong Kong, China +852 25911147 ; +852 28346627 ;
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Abstract
Despite the efforts made worldwide to reduce the number of cases of drug-susceptible tuberculosis, multidrug-resistant tuberculosis (MDR-TB) constitutes an important public health issue. Around 440,000 new cases of MDR-TB are estimated annually, although in 2008 only 7% of these (29,423 cases) were notified. The laboratory tests for diagnosing resistance may be phenotypic (based on culture growth in the presence of drugs) or genotypic (i.e. identification of the presence of mutations that confer resistance). The urgent need for a rapid means of detecting resistance to anti-TB drugs has resulted in the development of many genotypic methods over recent years. The treatment of MDR-TB is expensive, complex, prolonged (18-24 months) and associated with a higher incidence of adverse reactions. Some basic principles must be observed when prescribing an adequate treatment regimen for MDR-TB: (a) the association of at least four drugs (three of which should not have been used previously); (b) use of a fluoroquinolone; and (c) use of an injectable anti-TB drug. In Brazil, the therapeutic regimen for MDR-TB has been standardized and consists of five drugs: terizidone, levofloxacin, pyrazinamide, ethambutol and an aminoglycoside (streptomycin or amikacin). Pulmonary resection is an important tool in the coadjuvant treatment of MDR-TB. While a recent meta-analysis revealed an average cure rate of MDR-TB of 69%, clinical studies are currently being conducted with new drugs and with drugs already available on the market but with a new indication for TB, with encouraging results that will enable more effective treatment regimens to be planned in the future.
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Migliori GB, Centis R, D'Ambrosio L, Spanevello A, Borroni E, Cirillo DM, Sotgiu G. Totally drug-resistant and extremely drug-resistant tuberculosis: the same disease? Clin Infect Dis 2013; 54:1379-80. [PMID: 22492321 DOI: 10.1093/cid/cis128] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Giehl C, Lange C, Duarte R, Bothamley G, Gerlach C, Cirillo DM, Wagner D, Kampmann B, Goletti D, Juers T, Sester M. TBNET - Collaborative research on tuberculosis in Europe. Eur J Microbiol Immunol (Bp) 2012; 2:264-74. [PMID: 24265908 DOI: 10.1556/eujmi.2.2012.4.4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Accepted: 09/10/2012] [Indexed: 02/04/2023] Open
Abstract
Networking is a key feature of scientific success. The Tuberculosis Network European Trialsgroup (TBNET) was founded in 2006 as a non-profit, non-governmental peer-initiated scientific organization to collaboratively address research priorities in the area of tuberculosis in Europe. Today, TBNET is the largest tuberculosis research organization in Europe with nearly 500 members from 22 EU countries and 49 countries worldwide (www.tb-net.org). Apart from small multicenter basic research studies, a particular strength of TBNET is the performance of large collaborative projects, pan-European multicenter studies and database projects. In recent years, research from TBNET has substantially contributed to the understanding of the management, risk and prognosis of patients with multidrug (MDR) and extensively drug-resistant (XDR) tuberculosis and led to a better understanding of the clinical value of novel tests for the identification of adults and children with tuberculosis and latent infection with Mycobacterium tuberculosis. In 2009, two branches of TBNET were founded to specifically address tuberculosis in the pediatric population (ptbnet) and non-tuberculous mycobacterial diseases (NTM-NET). In addition to the research activities, TBNET is developing expert consensus documents for clinical management and provides training and capacity building especially for members from Eastern European countries, where tuberculosis is still a prevalent health problem.
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Arentz M, Pavlinac P, Kimerling ME, Horne DJ, Falzon D, Schünemann HJ, Royce S, Dheda K, Walson JL. Use of anti-retroviral therapy in tuberculosis patients on second-line anti-TB regimens: a systematic review. PLoS One 2012; 7:e47370. [PMID: 23144818 PMCID: PMC3489892 DOI: 10.1371/journal.pone.0047370] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 09/12/2012] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Use of antiretroviral therapy (ART) during treatment of drug susceptible tuberculosis (TB) improves survival. However, data from HIV infected individuals with drug resistant TB are lacking. Second line TB drugs when combined with ART may increase drug interactions and lead to higher rates of toxicity and greater noncompliance. This systematic review sought to determine the benefit of ART in the setting of second line drug therapy for drug resistant TB. METHODS We included individual patient data from studies that evaluated treatment of drug-resistant tuberculosis in HIV-1 infected individuals published between January 1980 and December of 2009. We evaluated the effect of ART on treatment outcomes, time to smear and culture conversion, and adverse events. RESULTS Ten observational studies, including data from 217 subjects, were analyzed. Patients using ART during TB treatment had increased likelihood of cure (hazard ratio (HR) 3.4, 95% CI 1.6-7.4) and decreased likelihood of death (HR 0.4, 95% CI 0.3-0.6) during treatment for drug resistant TB. These associations remained significant in patients with a CD4 less than 200 cells/mm(3) and less than 50 cells/mm(3), and when correcting for drug resistance pattern. LIMITATIONS We identified only observational studies from which individual patient data could be drawn. Limitations in study design, and heterogeneity in a number of the outcomes of interest had the potential to introduce bias. DISCUSSION While there are insufficient data to determine if ART use increases adverse drug interactions when used with second line TB drugs, ART use during treatment of drug resistant TB appears to improve cure rates and decrease risk of death. All individuals with HIV appear to benefit from ART use during treatment for TB.
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Affiliation(s)
- Matthew Arentz
- The University of Washington, Seattle, Washington, United States of America.
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Falzon D, Gandhi N, Migliori GB, Sotgiu G, Cox HS, Holtz TH, Hollm-Delgado MG, Keshavjee S, DeRiemer K, Centis R, D'Ambrosio L, Lange CG, Bauer M, Menzies D. Resistance to fluoroquinolones and second-line injectable drugs: impact on multidrug-resistant TB outcomes. Eur Respir J 2012; 42:156-68. [PMID: 23100499 DOI: 10.1183/09031936.00134712] [Citation(s) in RCA: 274] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A meta-analysis for response to treatment was undertaken using individual data of multidrug-resistant tuberculosis (MDR-TB) (resistance to isoniazid and rifampicin) patients from 26 centres. The analysis assessed the impact of additional resistance to fluoroquinolones and/or second-line injectable drugs on treatment outcome. Compared with treatment failure, relapse and death, treatment success was higher in MDR-TB patients infected with strains without additional resistance (n=4763; 64%, 95% CI 57-72%) or with resistance to second-line injectable drugs only (n=1130; 56%, 95% CI 45-66%), than in those having resistance to fluoroquinolones alone (n=426; 48%, 95% CI 36-60%) or to fluoroquinolones plus second-line injectable drugs (extensively drug resistant (XDR)-TB) (n=405; 40%, 95% CI 27-53%). In XDR-TB patients, treatment success was highest if at least six drugs were used in the intensive phase (adjusted OR 4.9, 95% CI 1.4-16.6; reference fewer than three drugs) and four in the continuation phase (OR 6.1, 95% CI 1.4-26.3). The odds of success in XDR-TB patients was maximised when the intensive phase reached 6.6-9.0 months duration and the total duration of treatment 20.1-25.0 months. In XDR-TB patients, regimens containing more drugs than those recommended in MDR-TB but given for a similar duration were associated with the highest odds of success. All data were from observational studies and methodologies varied between centres, therefore, the bias may be substantial. Better quality evidence is needed to optimise regimens.
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Affiliation(s)
- Dennis Falzon
- Stop TB Dept, World Health Organization, Geneva, Switzerland
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Matteelli A, Richardson MD, Sotgiu G, Centis R, Migliori GB. Multidrug- and extensively drug-resistant TB in persons living with HIV. Expert Rev Respir Med 2012; 3:245-54. [PMID: 20477319 DOI: 10.1586/ers.09.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) represent an emerging public health problem worldwide. The collision of the HIV epidemic with MDR- and XDR-TB has produced disastrous consequences for individual patients, with very high mortality rates reported in outbreaks among HIV-infected individuals. There is evidence of the importance of primary resistance among HIV-infected persons with XDR-TB, while the relevance of acquired resistance during inappropriate treatment among HIV-infected persons is uncertain, and TB case management of HIV-infected and -uninfected persons is based on similar standard practices to ensure treatment adherence. Current data show a limited geographical overlap of the XDR-TB and HIV epidemics: such data must be interpreted cautiously owing to the lack of adequate testing for both conditions. In fact, there are signs of an evolving epidemiological situation characterized by increased outbreak risk in concentrated areas owing to the extension of the HIV epidemic into areas of high MDR-TB prevalence and of the MDR-TB epidemic into areas of high HIV prevalence. There is a paucity of studies on treatment outcome among HIV-infected XDR-TB patients, and the only available report shows extremely high mortality rate and very short survival. Rapid diagnosis of TB and MDR-TB will be pivotal to reduce mortality among persons co-infected with HIV. However, while rapid diagnosis of MDR-TB is feasible with molecular assays on direct specimens, molecular approaches are still insensitive for XDR-TB diagnosis. There is speculative evidence that effective strategies for early HIV diagnosis and treatment will play a role in limiting the spread, and possibly improving the outcome of XDR-TB. Prevention is currently the mainstay of XDR-TB control in HIV communities. Strategies for infection control based on administrative procedures, environmental control and respiratory protection should be a priority for countries where both XDR-TB and HIV are prevalent. However, only the comprehensive implementation of the full Stop TB Strategy may be expected to curb the devastating impact of XDR-TB on HIV-infected persons.
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Affiliation(s)
- Alberto Matteelli
- Institute of Infectious & Tropical Diseases, University of Brescia, Piazza Spedali Civili, 1-25125 Brescia, Italy.
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Macedo R, Antunes A, Villar M, Portugal I. Multidrug and extensively drug-resistant tuberculosis in Lisbon and Vale do Tejo, Portugal, from 2008 to 2010. Int J Mycobacteriol 2012; 1:131-6. [DOI: 10.1016/j.ijmyco.2012.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 07/22/2012] [Indexed: 11/18/2022] Open
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