Treatment outcomes of drug-resistant tuberculosis in the Netherlands, 2005-2015

Risk factors for poor outcomes in patients with drug-resistant tuberculosis: a 6-year multicenter prospective study in Zhejiang, China

BACKGROUND

At present, the disease burden of drug-resistant tuberculosis (DR-TB) is still heavy in the world. In this study, we aimed to evaluate the success rate of DR-TB patients after standardized treatment and to analyze the risk factors for poor outcomes in Zhejiang, China.

METHODS

From 2017 to 2021, all culture-confirmed tuberculosis (TB) patients were prospectively enrolled from three designated TB hospitals in Zhejiang, China. Demographic surveys were conducted in all patients, and drug susceptibility of TB strains was tested by fluorescent polymerase chain reaction probe melting curve analysis (MeltPro). DR-TB patients were treated with WHO recommended standardized treatment according to the type of drug resistance, and the outcomes were thoroughly monitored and tracked until June 2023. Binary logistic regression model was used to analyze the related risk factors of poor outcomes in patients with DR-TB. The patients' socio-demographic information, comorbidities, fever, antibiotic use, laboratory test results, lung imaging characteristics and drug resistance characteristics were included in the analysis. A simple TB severity score was developed according to the WHO definition and applied to the analysis.

RESULTS

Among 1013 patients with confirmed TB, 779 were sensitive to all of the tested drugs (rifampicin, isoniazid, ethambutol, streptomycin and fluoroquinolones), and 234 were resistant to at least one tested drug. Among the 234 DR-TB patients in the study, 50 patients had poor outcomes (23 cases of failure, 13 cases of death, and 14 patients lost to follow-up), 158 patients were successfully treated (125 cases were cured and 33 cases completed treatment), and 26 were referred to other provinces. The overall treatment success rate was 76.0% (158/208). Multivariate analysis showed that age (AOR 1.03; 95%CI 1.01-1.05), previous TB treatment history (AOR 5.03; 95%CI 1.33-18.99), higher TB severity score (AOR 1.48; 95%CI 1.09-2.03), MDR/RR-TB (AOR 8.34; 95%CI 2.99-23.24) and pre-XDR-TB (AOR 9.50; 95%CI 2.24-40.26) were independent risk factors for poor outcomes in DR-TB patients.

CONCLUSIONS

The treatment success rate of DR-TB patients in this study reached that of the WHO standard treatment (75%). Physicians should be alert to the possibility of poor outcomes in DR-TB patients with old age, previous TB treatment history, higher TB severity score, MDR/RR-TB or pre-XDR-TB.

Predictors of treatment delay among drug resistant tuberculosis patients in Uganda

BACKGROUND

Drug resistant tuberculosis (DR-TB) continues to be a significant global public health concern despite the availability of effective TB medicines. Equally, delayed DR-TB treatment initiation is associated with increased morbidity, amplified resistance, transmission risk and poor treatment outcomes. This study aimed to investigate treatment delays and identify predictors of delayed treatment initiation among DR-TB patients in Uganda.

METHOD

A retrospective study was conducted using routine DR-TB national case registration data between January 2012 and December 2019. Stata version 15 was used to run uni-variate analysis to describe patient characteristics using frequencies and percentages; bivariate analysis to identify significant differences in median times to treatment initiation; and logistic regression model was fitted, and adjusted odds ratio (AOR) with 95% confidence interval was used to identify factors associated with DR-TB treatment delay.

RESULTS

A total of 2,166 DR-TB patients were included in this study. The median treatment initiation delay was 10 days. Approximately 57% of DR-TB patients experienced delays in starting their treatment beyond the acceptable 7-day timeframe. Being diagnosed as RR-TB [AOR = 1.22; 95% CI: 1.08-1.37], and being a recurrent TB patient [AOR = 1.22; 95% CI: 1.01-1.47] were associated with treatment delays. Patients with previous history of 'lost to follow-up' (LTFU), failure and being diagnosed as Pre-XDR-TB were less inclined to delay DR-TB treatment.

CONCLUSION

Several DR-TB patients experienced treatment delay. The delay was significant among patients diagnosed as RR-TB and those with TB treatment history of recurrent TB. This highlights the need for heightened vigilance among healthcare workers when managing DR-TB patients with a history of past TB treatment and those diagnosed as RR-TB to minimize delays. Furthermore, future research should investigate a comprehensive list of variables influencing the timing of treatment initiation after diagnosis. An in-depth understanding of the effects of these factors can inform targeted interventions to optimize treatment strategies for improved DR-TB patient outcomes.

Treatment outcomes of standardized injectable shorter regimen for multi-drugs resistant tuberculosis in Ethiopia: a retrospective cohort study

BACKGROUND

The injectable shorter multi-drug resistant tuberculosis (MDR-TB) regimen, has been reported to be less costly and more effective in the treatment of MDR-TB compared to the longer regimen. Ethiopia introduced the injectable shorter regimen (SR) in April 2018 following official recommendation by the World Health Organization (WHO) in 2016. While the WHO recommendation was based on evidence coming from extensive programmatic studies in some Asian and African countries, there is paucity of information on patient outcomes in the Ethiopian context. Thus, we aimed to assess the treatment outcomes and identify factors associated with the outcomes of MDR-TB patients on injectable SR.

METHODS

A multi-center facility-based retrospective cohort study was conducted in Ethiopia on 245 MDR-TB patients who were treated between April 2018 and March 2020. Data were collected from patients' medical records and analyzed using SPSS version 25. Descriptive statistics was used to summarize the results while inferential analysis was employed to investigate predictors of treatment outcomes and survival status.

RESULTS

A total of 245 patients were included in the study, with 129 (52.7%) of them being female. Median age of the patients was 27 (IQR: 21-33). The overall treatment success rate was 87.8%, with 156 (63.7%) cured and 59 (24.1%) patients who completed treatment. The unfavorable outcomes accounted for 12.2%, with 16 (6.5%) treatment failure, 8 (3.3%) death and 6 (2.4%) lost to follow up. Majority of the unfavorable outcomes occurred during the early phase of therapy, with median time to event of 1.8 months (95% CI: 0.99-2.69). The use of khat (a green leafy shrub abused for its stimulant like effect) and being diagnosed with MDR-TB than rifampicin resistant only, were identified as independent factors associated with unfavorable outcomes.

CONCLUSION

The injectable SR for MDR-TB was found to have positive treatment outcomes in the context of programmatic management in Ethiopia.

Development and validation of a prediction model for unsuccessful treatment outcomes in patients with multi-drug resistance tuberculosis

BACKGROUND

The World Health Organization has reported that the treatment success rate of multi-drug resistance tuberculosis is approximately 57% globally. Although new drugs such as bedaquiline and linezolid is likely improve the treatment outcome, there are other factors associated with unsuccessful treatment outcome. The factors associated with unsuccessful treatment outcomes have been widely examined, but only a few studies have developed prediction models. We aimed to develop and validate a simple clinical prediction model for unsuccessful treatment outcomes in patients with multi-drug resistance pulmonary tuberculosis (MDR-PTB).

METHODS

This retrospective cohort study was performed between January 2017 and December 2019 at a special hospital in Xi'an, China. A total of 446 patients with MDR-PTB were included. Least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression were used to select prognostic factors for unsuccessful treatment outcomes. A nomogram was built based on four prognostic factors. Internal validation and leave-one-out cross-validation was used to assess the model.

RESULTS

Of the 446 patients with MDR-PTB, 32.9% (147/446) cases had unsuccessful treatment outcomes, and 67.1% had successful outcomes. After LASSO regression and multivariate logistic analyses, no health education, advanced age, being male, and larger extent lung involvement were identified as prognostic factors. These four prognostic factors were used to build the prediction nomograms. The area under the curve of the model was 0.757 (95%CI 0.711 to 0.804), and the concordance index (C-index) was 0.75. For the bootstrap sampling validation, the corrected C-index was 0.747. In the leave-one-out cross-validation, the C-index was 0.765. The slope of the calibration curve was 0.968, which was approximately 1.0. This indicated that the model was accurate in predicting unsuccessful treatment outcomes.

CONCLUSIONS

We built a predictive model and established a nomogram for unsuccessful treatment outcomes of multi-drug resistance pulmonary tuberculosis based on baseline characteristics. This predictive model showed good performance and could be used as a tool by clinicians to predict who among their patients will have an unsuccessful treatment outcome.

The differences in drug resistance between drug-resistant tuberculosis patients with and without diabetes mellitus in northeast China: a retrospective study

BACKGROUND

Diabetes mellitus (DM) and drug-resistant tuberculosis (DR-TB) are serious global public health problems. This study aimed to explore the differences in drug resistance between DR-TB patients with and without DM. Risk factors for developing multidrug-resistant tuberculosis (MDR-TB) were also investigated among DR-TB patients.

METHODS

The patient's basic demographic,　clinical characteristics, and drug susceptibility testing (DST) data were collected from the Chinese Disease Control Information System. Descriptive statistics were used to estimate the frequency and proportion of included variables. Categorical variables were compared using the Chi-square test or Fisher's exact test. Chi-square tests for trends were used to determine changes and trends in MDR-TB and pre-extensively drug-resistantTB (pre-XDR-TB) patterns over time. Univariate and multivariate logistic regression analysis was used to explore the risk factors of MDR-TB.

RESULTS

Compared with DR-TB patients with DM, DR-TB patients without DM had significantly higher rates of mono-resistant streptomycin (SM) and any resistance to kanamycin (KM), but significantly lower rates of any resistance to protionamide (PTO) and mono-resistance to levofloxacin (LFX), and pre-XDR-TB (P<0.05). The proportion of resistance to other anti-TB drugs was not statistically different between the DR-TB with and without DM. Among DR-TB patients without and with DM, the proportion of patients with MDR-TB and pre-XDR-TB patterns showed a significant downward trend from 2016 to 2021 (P<0.05). Among DR-TB patients without DM, male, previously treated DR-TB cases, and immigration were risk factors for MDR-TB (P<0.05). In DR-TB patients with DM, a negative sputum smear is a risk factor for MDR-TB (P<0.05).

CONCLUSION

There was no statistical difference in resistance patterns between DR-TB with and without DM, except in arbitrary resistance to PTO and KM, mono-resistant SM and LFX, and pre-XDR-TB. Great progress has been made in the prevention and control of MDR-TB and pre-XDR-TB. However, DR-TB patients with and without DM differ in their risk factors for developing MDR-TB.

Long-term treatment outcomes in patients with multidrug-resistant tuberculosis

OBJECTIVES

To describe long-term treatment outcomes in patients with multi-drug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) and validate established outcome definitions for MDR/RR-TB treatment.

METHODS

Among patients with MDR/RR-TB admitted to a German MDR/RR-TB referral centre from 1 September 2002 to 29 February 2020, we compared long-term treatment outcomes derived from individual patient follow-up with treatment outcomes defined by WHO-2013, WHO-2021 and the Tuberculosis Network European Trials Group-2016.

RESULTS

In a total of 163 patients (mean age, 35 years; standard deviation, 13 years; 14/163 [8.6%] living with HIV; 109/163 [66.9%] men, 149/163 [91.4%] migrating to Germany within 5 years), the treatment of culture-confirmed MDR/RR-TB was initiated. Additional drug resistance to a fluoroquinolone or a second-line injectable agent was present in 15 of the 163 (9.2%) Mycobacterium tuberculosis strains; resistance against both the drug classes was present in 29 of the 163 (17.8%) strains. The median duration of MDR/RR-TB treatment was 20 months (interquartile range, 19.3-21.6 months), with a medium of five active drugs included. The median follow-up time was 4 years (47.7 months; interquartile range, 21.7-65.8 months). Among the 163 patients, cure was achieved in 25 (15.3%), 82 (50.3%) and 95 (58.3%) patients according to the outcome definitions of WHO-2013, WHO-2021, and the Tuberculosis Network European Trials Group-2016, respectively. The lost to follow-up rate was 17 of 163 (10.4%). Death was more likely in patients living with HIV (hazard ratio, 4.28; 95% confidence interval, 1.26-12.86) and older patients (hazard ratio, 1.08; 95% confidence interval, 1.05-1.12; increment of 1 year). Overall, 101/163 (62.0%) patients experienced long-term, relapse-free cure; of those, 101/122 (82.8%) patients with a known status (not lost to-follow-up or transferred out) at follow-up.

CONCLUSION

Under optimal management conditions leveraging individualized treatment regimens, long-term, relapse-free cure from MDR/RR-TB is substantially higher than cure rates defined by current treatment outcome definitions.

Barriers to Optimal Tuberculosis Treatment Services at Community Health Centers: A Qualitative Study From a High Prevalent Tuberculosis Country

Background: Community health centers (CHCs) are a backbone healthcare facility for tuberculosis (TB) services. Identifying barriers amongst TB service providers at the CHC level is required to help them deliver successful TB treatment.

Aims: The current study aimed to analyze barriers to successful TB treatment from the perspective of TB service providers at the CHC level in a high prevalent TB country.

Methods: A qualitative study was conducted using in-depth interviews and focus group discussions in a province of Indonesia with a high TB prevalence. Two districts representing rural and urban areas were selected to obtain information from TB service providers (i.e., physicians and nurses) at the CHC level. In addition, key informant interviews with TB patients, hospital TB specialists, pharmacists, and activists were conducted. The trustworthiness and credibility of the information were established using information saturation, participant validation, and triangulation approaches. The interviews were also transcribed for the inductive analysis using Atlas.ti 8.4 software.

Results: We identified 210 meaning units from 48 participants and classified them into two main themes: organizational capacity and TB program activities. We identified the inadequacy of human resources, facility, and external coordination as the main barriers to organizational capacity. Furthermore, the barriers were identified regarding TB program activities, that is, inadequate TB case finding, diagnosis, drug supply chain and dispensing management, treatment and monitoring, case recording and reporting, and public-private collaboration.

Conclusion: Strengthening CHCs in the management of TB is critical to reaching the national and global goals of TB eradication by 2035. These findings can be considered to develop evaluation strategies to improve the successful TB treatment in high prevalent TB countries, especially Indonesia.

Impact of Treatment Supporters on the Treatment Outcomes of Drug Resistant-Tuberculosis (DR-TB) Patients: A Retrospective Cohort Study

Background: Drug resistant-tuberculosis (DR-TB) patients are provided universal drug susceptibility testing (UDST), anti-TB drugs for the treatment of DR-TB, nutritional support (Nikshay Poshan Yojana - the financial incentive of rupees five hundred per month for each notified DR-TB patient for the duration for which the patient is on anti-TB drugs) by the Government of India.

Methods: This retrospective cohort record-based study was conducted in DR-TB patients. Some 1095 DR-TB patients who have initiated treatment at Nodal DR-TB Centre, Darbhanga Medical College and Hospital (DMCH), Darbhanga, and continued their anti-TB drugs at home blocks were followed till their treatment outcome was known. Data were analyzed by statistical experts of DMCH.

Results: Treatment supporters comprised 688 (62.83%) females and 407 (37.17%) males. Different types of treatment supporters noted were accredited social health activists (ASHAs) 622 (56.80%), family members 365 (33.33%), and community health workers 108 (09.86%). Treatment outcome as transfer out was observed in 08 (1.29%), 10 (2.74%), and 13 (12.03%) cases among ASHAs, family members, and community health workers, respectively [statistically significant (p < 0.0001)].

Conclusion: ASHAs proved to be the best treatment supporters in comparison to both family members and community health workers for multi-drug resistant TB (MDR/RR-TB) patients.

Incidence and predictors of mortality among persons receiving second-line tuberculosis treatment in sub-Saharan Africa: A meta-analysis of 43 cohort studies

BACKGROUND

Drug resistance remains from among the most feared public health threats that commonly challenges tuberculosis treatment success. Since 2010, there have been rapid evolution and advances to second-line anti-tuberculosis treatments (SLD). However, evidence on impacts of these advances on incidence of mortality are scarce and conflicting. Estimating the number of people died from any cause during the follow-up period of SLD as the incidence proportion of all-cause mortality is the most informative way of appraising the drug-resistant tuberculosis treatment outcome. We thus aimed to estimate the pooled incidence of mortality and its predictors among persons receiving the SLD in sub-Saharan Africa.

METHODS

We systematically identified relevant studies published between January, 2010 and March, 2020, by searching PubMed/MEDLINE, EMBASE, SCOPUS, Cochrane library, Google scholar, and Health Technology Assessment. Eligible English-language publications reported on death and/or its predictors among persons receiving SLD, but those publications that reported death among persons treated for extensively drug-resistant tuberculosis were excluded. Study features, patients' clinical characteristics, and incidence and/or predictors of mortality were extracted and pooled for effect sizes employing a random-effects model. The pooled incidence of mortality was estimated as percentage rate while risks of the individual predictors were appraised based on their independent associations with the mortality outcome.

RESULTS

A total of 43 studies were reviewed that revealed 31,525 patients and 4,976 deaths. The pooled incidence of mortality was 17% (95% CI: 15%-18%; I2 = 91.40; P = 0.00). The studies used varied models in identifying predictors of mortality. They found diagnoses of clinical conditions (RR: 2.36; 95% CI: 1.82-3.05); excessive substance use (RR: 2.56; 95% CI: 1.78-3.67); HIV and other comorbidities (RR: 1.96; 95% CI: 1.65-2.32); resistance to SLD (RR: 1.75; 95% CI: 1.37-2.23); and male sex (RR: 1.82; 95% CI: 1.35-2.44) as consistent predictors of the mortality. Few individual studies also reported an increased incidence of mortality among persons initiated with the SLD after a month delay (RR: 1.59; 95% CI: 0.98-2.60) and those persons with history of tuberculosis (RR: 1.21; 95% CI: 1.12-1.32).

CONCLUSIONS

We found about one in six persons who received SLD in sub-Saharan Africa had died in the last decade. This incidence of mortality among the drug-resistant tuberculosis patients in the sub-Saharan Africa mirrors the global average. Nevertheless, it was considerably high among the patients who had comorbidities; who were diagnosed with other clinical conditions; who had resistance to SLD; who were males and substance users. Therefore, modified measures involving shorter SLD regimens fortified with newer or repurposed drugs, differentiated care approaches, and support of substance use rehabilitation programs can help improve the treatment outcome of persons with the drug-resistant tuberculosis.

TRIAL REGISTRATION NUMBER

CRD42020160473; PROSPERO.

Gender differences among patients with drug resistant tuberculosis and HIV co-infection in Uganda: a countrywide retrospective cohort study

BACKGROUND

Gender differences among patients with drug resistant tuberculosis (DRTB) and HIV co-infection could affect treatment outcomes. We compared characteristics and treatment outcomes of DRTB/HIV co-infected men and women in Uganda.

METHODS

We conducted a retrospective chart review of patients with DRTB from 16 treatment sites in Uganda. Eligible patients were aged ≥ 18 years, had confirmed DRTB, HIV co-infection and a treatment outcome registered between 2013 and 2019. We compared socio-demographic and clinical characteristics and tuberculosis treatment outcomes between men and women. Potential predictors of mortality were determined by cox proportional hazard regression analysis that controlled for gender. Statistical significance was set at p < 0.05.

RESULTS

Of 666 DRTB/HIV co-infected patients, 401 (60.2%) were men. The median (IQR) age of men and women was 37.0 (13.0) and 34.0 (13.0) years respectively (p < 0.001). Men were significantly more likely to be on tenofovir-based antiretroviral therapy (ART), high-dose isoniazid-containing DRTB regimen and to have history of cigarette or alcohol use. They were also more likely to have multi-drug resistant TB, isoniazid and streptomycin resistance and had higher creatinine, aspartate and gamma-glutamyl aminotransferase and total bilirubin levels. Conversely, women were more likely to be unemployed, unmarried, receive treatment from the national referral hospital and to have anemia, a capreomycin-containing DRTB regimen and zidovudine-based ART. Treatment success was observed among 437 (65.6%) and did not differ between the genders. However, mortality was higher among men than women (25.7% vs. 18.5%, p = 0.030) and men had a shorter mean (standard error) survival time (16.8 (0.42) vs. 19.0 (0.46) months), Log Rank test (p = 0.046). Predictors of mortality, after adjusting for gender, were cigarette smoking (aHR = 4.87, 95% CI 1.28-18.58, p = 0.020), an increase in alanine aminotransferase levels (aHR = 1.05, 95% CI 1.02-1.07, p < 0.001), and history of ART default (aHR = 3.86, 95% CI 1.31-11.37, p = 0.014) while a higher baseline CD4 count was associated with lower mortality (aHR = 0.94, 95% CI 0.89-0.99, p = 0.013 for every 10 cells/mm³ increment).

CONCLUSION

Mortality was higher among men than women with DRTB/HIV co-infection which could be explained by several sociodemographic and clinical differences.

Barriers and strategies to successful tuberculosis treatment in a high-burden tuberculosis setting: a qualitative study from the patient's perspective

Background

Previously treated tuberculosis (TB) patients are a widely reported risk factor for multidrug-resistant tuberculosis. Identifying patients’ problems during treatment is necessary to control TB, especially in a high-burden setting. We therefore explored barriers to successful TB treatment from the patients’ perspective, aiming to identify potential patient-centred care strategies to improve TB treatment outcome in Indonesia.

Methods

A qualitative study was conducted in a province of Indonesia with high TB prevalence. Participants from various backgrounds (i.e., TB patients, physicians, nurses, pharmacists, TB activist, TB programmers at the district and primary care levels) were subject to in-depth interviews and focus group discussions (FGDs). All interviews and FGDs were transcribed verbatim from audio and visual recordings and the respective transcriptions were used for data analysis. Barriers were constructed by interpreting the codes’ pattern and co-occurrence. The information’s trustworthiness and credibility were established using information saturation, participant validation and triangulation approaches. Data were inductively analysed using the Atlas.ti 8.4 software and reported following the COREQ 32-items.

Results

We interviewed 63 of the 66 pre-defined participants and identified 15 barriers. The barriers were classified into three themes, i.e., socio-demography and economy; knowledge and perception and TB treatment. Since the barriers can be interrelated, we determined five main barriers across all barrier themes, i.e., lack of TB knowledge, stigmatisation, long distance to the health facility, adverse drug reaction and loss of household income.

Conclusion

The main treatment barriers can be considered to strengthen patient-centred care for TB patients in Indonesia. A multi-component approach including TB patients, healthcare providers, broad community and policy makers is required to improve TB treatment success.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12005-y.

Risk factor for 31-day unplanned readmission to hospital in patients with pulmonary tuberculosis in China

OBJECTIVES

To evaluate risk factors associated with 31-day unplanned readmission(s) for pulmonary tuberculosis (TB) in China.

METHODS

This retrospective study enrolled patients (age, >14 years) with pulmonary TB who experienced 31-day unplanned readmissions to a specialized hospital for TB between January 2018 and December 2019. For each confirmed readmission, 2 control subjects were randomly selected from among patients with pulmonary TB but did not experience an unplanned readmission within 31 days.

RESULTS

A total of 402 pulmonary TB patients (5.9%) experienced unplanned readmission within 31 days after discharge. In univariate analysis, readmission was associated with gender, age, insurance coverage, residing in a rural area, active smoking, chronic obstructive pulmonary disease (COPD), drug-induced hepatitis, and leaving hospital against medical advice. The final logistic regression model revealed that higher risks for unplanned readmissions were associated with male gender (odds ratio [OR] 1.44, [95% confidence interval (CI) : 1.06-1.95]), age >65 years (OR 2.94, 95%CI: 2.03-4.27), rural residence (OR 8.86, 95%CI: 6.61-11.87), active smoking (OR 2.15, 95% CI 1.37-3.40), COPD (OR 2.77, 95%CI: 1.59-4.81), and leaving hospital against physician advice (OR 4.11, 95%CI: 1.43-11.83). The median time to 31-day unplanned readmission was 24 days. Major reasons for unplanned readmission included fever, exacerbation of dyspnea, and hemoptysis.

CONCLUSION

Unplanned readmission for pulmonary TB within 31 days of discharge was higher among older males residing in rural areas, active smokers, and those leaving hospital against medical advice.

Predictors of mortality in patients with drug-resistant tuberculosis: A systematic review and meta-analysis

BACKGROUND

Even though the lives of millions have been saved in the past decades, the mortality rate in patients with drug-resistant tuberculosis is still high. Different factors are associated with this mortality. However, there is no comprehensive global report addressing these risk factors. This study aimed to determine the predictors of mortality using data generated at the global level.

METHODS

We systematically searched five electronic major databases (PubMed/Medline, CINAHL, EMBASE, Scopus, Web of Science), and other sources (Google Scholar, Google). We used the Joanna Briggs Institute Critical Appraisal tools to assess the quality of included articles. Heterogeneity assessment was conducted using the forest plot and I2 heterogeneity test. Data were analyzed using STATA Version 15. The pooled hazard ratio, risk ratio, and odd's ratio were estimated along with their 95% CIs.

RESULT

After reviewing 640 articles, 49 studies met the inclusion criteria and were included in the final analysis. The predictors of mortality were; being male (HR = 1.25,95%CI;1.08,1.41,I2;30.5%), older age (HR = 2.13, 95%CI;1.64,2.62,I2;59.0%,RR = 1.40,95%CI; 1.26, 1.53, I2; 48.4%) including a 1 year increase in age (HR = 1.01, 95%CI;1.00,1.03,I2;73.0%), undernutrition (HR = 1.62,95%CI;1.28,1.97,I2;87.2%, RR = 3.13, 95% CI; 2.17,4.09, I2;0.0%), presence of any type of co-morbidity (HR = 1.92,95%CI;1.50-2.33,I2;61.4%, RR = 1.61, 95%CI;1.29, 1.93,I2;0.0%), having diabetes (HR = 1.74, 95%CI; 1.24,2.24, I2;37.3%, RR = 1.60, 95%CI;1.13,2.07, I2;0.0%), HIV co-infection (HR = 2.15, 95%CI;1.69,2.61, I2; 48.2%, RR = 1.49, 95%CI;1.27,1.72, I2;19.5%), TB history (HR = 1.30,95%CI;1.06,1.54, I2;64.6%), previous second-line anti-TB treatment (HR = 2.52, 95% CI;2.15,2.88, I2;0.0%), being smear positive at the baseline (HR = 1.45, 95%CI;1.14,1.76, I2;49.2%, RR = 1.58,95%CI;1.46,1.69, I2;48.7%), having XDR-TB (HR = 2.01, 95%CI;1.50,2.52, I2;60.8%, RR = 2.44, 95%CI;2.16,2.73,I2;46.1%), and any type of clinical complication (HR = 2.98, 95%CI; 2.32, 3.64, I2; 69.9%). There are differences and overlaps of predictors of mortality across different drug-resistance categories. The common predictors of mortality among different drug-resistance categories include; older age, presence of any type of co-morbidity, and undernutrition.

CONCLUSION

Different patient-related demographic (male sex, older age), and clinical factors (undernutrition, HIV co-infection, co-morbidity, diabetes, clinical complications, TB history, previous second-line anti-TB treatment, smear-positive TB, and XDR-TB) were the predictors of mortality in patients with drug-resistant tuberculosis. The findings would be an important input to the global community to take important measures.

Evaluation of drug-resistant tuberculosis treatment outcome in Portugal, 2000-2016

Treatment of drug-resistant tuberculosis (TB), which is usually less successful than that of drug-susceptible TB, represents a challenge for TB control and elimination. We aimed to evaluate treatment outcomes and to identify the factors associated with death among patients with MDR and XDR-TB in Portugal. We assessed MDR-TB cases reported for the period 2000-2016, using the national TB Surveillance System. Treatment outcomes were defined according to WHO recommendations. We identified the factors associated with death using logistic regression. We evaluated treatment outcomes of 294 MDR- and 142 XDR-TB patients. The treatment success rate was 73.8% among MDR- and 62.7% among XDR-TB patients (p = 0.023). The case-fatality rate was 18.4% among MDR- and 23.9% among XDR-TB patients. HIV infection (OR 4.55; 95% CI 2.31-8.99; p < 0.001) and resistance to one or more second-line injectable drugs (OR 2.73; 95% CI 1.26-5.92; p = 0.011) were independently associated with death among MDR-TB patients. HIV infection, injectable drug use, past imprisonment, comorbidities, and alcohol abuse are conditions that were associated with death early on and during treatment. Early diagnosis of MDR-TB and further monitoring of these patients are necessary to improve treatment outcome.

Risk factors for mortality among patients diagnosed with multi-drug resistant tuberculosis in Uganda- a case-control study

Background

The World Health Organization (WHO) End TB strategy aims to reduce mortality due to tuberculosis (TB) to less than 5% by 2035. However, mortality due to multidrug-resistant tuberculosis (MDR-TB) remains particularly high. Globally, almost 20% of patients started on MDR-TB treatment die during the course of treatment every year. We set out to examine the risk factors for mortality among a cohort of patients diagnosed with MDR-TB in Uganda.

Methods

We conducted a case-control study nested within the national MDR-TB cohort. We defined cases as patients who died from any cause during the course of MDR-TB treatment. We selected two controls for each case from patients alive and on MDR-TB treatment at the time that the death occurred (incidence-density sampling). We matched the cases and controls on health facility at which they were receiving care. We performed conditional logistic regression to identify the risk factors for mortality.

Results

Data from 198 patients (66 cases and 132 controls) started on MDR-TB treatment from January 1 to December 31, 2016, was analyzed for this study. Cases were similar to controls in age/sex distribution, occupation and history of TB treatment. However, cases were more likely to be HIV infected while controls were more likely to have attained secondary level education. On multivariate regression analysis, co-infection with HIV (aOR 1.9, 95% CI [1.1–4.92] p = 0.05); non-adherence to MDR-TB treatment (aOR 1.92, 95% CI [1.02–4.83] p = 0.04); age over 50 years (aOR 3.04, 95% CI [1.13–8.20] p = 0.03); and having no education (aOR 3.61, 95% CI [1.1–10.4] p = 0.03) were associated with MDR-TB mortality.

Conclusion

To mitigate MDR-TB mortality, attention must be paid to provision of social support particularly for older persons on MDR-TB treatment. In addition, interventions that support treatment adherence and promote early detection and management of TB among HIV infected persons should also be emphasized.

Characteristics of pulmonary multidrug-resistant tuberculosis patients in Tigray Region, Ethiopia: A cross-sectional study

BACKGROUND

Tuberculosis (TB) is among the top 10 causes of mortality and the first killer among infectious diseases worldwide. One of the factors fuelling the TB epidemic is the global rise of multidrug resistant TB (MDR-TB). The aim of this study was to determine the magnitude and factors associated with MDR-TB in the Tigray Region, Ethiopia.

METHOD

This study employed a facility-based cross-sectional study design, which was conducted between July 2018 and August 2019. The inclusion criteria for the study participants were GeneXpert-positive who were not under treatment for TB, PTB patients' ≥15 years of age and who provided written informed consent. A total of 300 participants were enrolled in the study, with a structured questionnaire used to collect data on clinical, sociodemographic and behavioral factors. Sputum samples were collected and processed for acid-fast bacilli staining, culture and drug susceptibility testing. Drug susceptibility testing was performed using a line probe assay. Logistic regression was used to analyze associations between outcome and predictor variables.

RESULTS

The overall proportion of MDR-TB was 16.7% (11.6% and 32.7% for new and previously treated patients, respectively). Of the total MDR-TB isolates, 5.3% were pre-XDR-TB. The proportion of MDR-TB/HIV co-infection was 21.1%. A previous history of TB treatment AOR 3.75; 95% CI (0.7-2.24), cigarette smoking AOR 6.09; CI (1.65-2.50) and patients who had an intermittent fever (AOR = 2.54, 95% CI = 1.21-5.4) were strongly associated with MDR-TB development.

CONCLUSIONS

The magnitude of MDR-TB observed among new and previously treated patients is very alarming, which calls for an urgent need for intervention. The high proportion of MDR-TB among newly diagnosed cases indicates ongoing transmission, which suggests the need for enhanced TB control program performance to interrupt transmission. The increased proportion of MDR-TB among previously treated cases indicates a need for better patient management to prevent the evolution of drug resistance. Assessing the TB control program performance gaps and an optimal implementation of the WHO recommended priority actions for the management of drug-resistant TB, is imperative to help reduce the current high MDR-TB burden in the study region.

Miliary pattern, a classic pulmonary finding of tuberculosis disease

Introduction

The increase in age of the population and in the use of immunosuppressive treatment makes tuberculosis (TB) with hematogenous or lymphatic dissemination a current problem.

Methods

We collected all the patients diagnosed with tuberculosis with miliary pulmonary pattern at the Santiago de Compostela University Teaching Hospital (NW Spain) from 1 January 2006 to 31 December 2015.

Results

A total of 27 patients were included, 70.4% women, with a median age of 69.0 years old. A cause of immunosuppression was observed only in 51.9% of patients. The majority of the cases (65.0%) presented pulmonary affectation. The most frequently isolated species was Mycobacterium tuberculosis (88.9%). Multiresistance to first-line antituberculosis drugs was observed only in 3.7%. 92.6% of the patients received treatment with Isoniazid, Rifampicin and Pyrazinamine, associated in 48.1% of them with Ethambutol. Two patients died during admission and there were no recurrences in the 2-years follow-up.

Conclusions

Miliary tuberculosis remains a current pathology. Most patients do not have a known cause of immunosuppression. The response to the typical treatment is usually good.

High Prevalence of Rifampicin Resistance Associated with Rural Residence and Very Low Bacillary Load among TB/HIV-Coinfected Patients at the National Tuberculosis Treatment Center in Uganda

Background

Rifampicin resistance (RR) is associated with mortality among tuberculosis (TB) patients coinfected with HIV. We compared the prevalence of RR among TB patients with and without HIV coinfection at the National Tuberculosis Treatment Center (NTTC) in Uganda, a TB/HIV high burdened country. We further determined associations of RR among TB/HIV-coinfected patients.

Methods

In this secondary analysis, we included adult (≥18 years) bacteriologically confirmed TB patients that were enrolled in a cross-sectional study at the NTTC in Uganda between August 2017 and March 2018. TB, RR, and bacillary load were confirmed by the Xpert® MTB/RIF assay in the primary study. A very low bacillary load was defined as a cycle threshold value of >28. We compared the prevalence of RR among TB patients with and without HIV coinfection using Pearson's chi-square test. We performed logistic regression analysis to determine associations of RR among TB/HIV-coinfected patients.

Results

Of the 303 patients, 182 (60.1%) were male, 111 (36.6%) had TB/HIV coinfection, and the median (interquartile range) age was 31 (25-39) years. RR was found among 58 (19.1%) patients. The prevalence of RR was 32.4% (36/111) (95% confidence interval (CI): 24-42) among TB/HIV-coinfected patients compared to 11.5% (22/192) (95% CI: 7–17) among HIV-negative TB patients (p < 0.001). Among TB/HIV-coinfected patients, those with RR were more likely to be rural residents (adjusted odds ratio (aOR): 5.24, 95% CI: 1.51–18.21, p = 0.009) and have a very low bacillary load (aOR: 13.52, 95% CI: 3.15–58.08, p < 0.001).

Conclusion

There was a high prevalence of RR among TB/HIV-coinfected patients. RR was associated with rural residence and having a very low bacillary load among TB/HIV-coinfected patients. The findings highlight a need for universal access to drug susceptibility testing among TB/HIV-coinfected patients, especially in rural settings.

Interventions to improve medication adherence in tuberculosis patients: a systematic review of randomized controlled studies

Non-adherence to anti-tuberculosis (anti-TB) medication is a major risk factor for poor treatment outcomes. We therefore assessed the effectiveness of medication adherence enhancing interventions in TB patients. We report a systematic review of randomized controlled trials that included either latent tuberculosis infection (LTBI) or active TB patients. Outcomes of interest included adherence rate, completed treatment, defaulted treatment and treatment outcomes. We identified four LTBI and ten active TB studies. In active TB patients, directly observed treatment (DOT) by trained community workers, short messaging service combined with education, counselling, monthly TB vouchers, drug box reminders and combinations of those were found effective. In LTBI patients, shorter regimens and DOT effectively improved treatment completion. Interestingly, DOT showed variable effectiveness, highlighting that implementation, population and setting may play important roles. Since non-adherence factors are patient-specific, personalized interventions are required to enhance the impact of a programme to improve medication adherence in TB patients.

Characteristics of Poor Tuberculosis Treatment Outcomes among Patients with Pulmonary Tuberculosis in Community Hospitals of Thailand

Pulmonary tuberculosis (TB) is a major global public health problem. Thailand is listed as one of the countries with a high burden of pulmonary TB. Various factors are known to contribute to unsuccessful pulmonary TB treatment. However, studies in Thailand remain limited, especially in rural settings. This study aimed to identify the prevalence and associated factors of unsuccessful pulmonary TB treatment in community hospitals. A cross-sectional study was conducted from June-July 2019. We enrolled all patients receiving treatments in four community hospitals in central Thailand. The collected data included baseline characteristics, comorbid illnesses, a history of directly observed treatment-short course (DOTS), sputum acid-fast bacilli smear results, and chest radiography and treatment outcomes. Univariate and multivariate analyses were used to identify factors associated with unsuccessful pulmonary TB treatment. A total of 786 patients were enrolled in the study. Prevalence of unsuccessful treatment was 18.7%. Associated factors of unsuccessful pulmonary TB treatment were previously treated TB (adjusted odds ratio [AOR]: 2.1, 95% CI: 1.2-3.7), existence of comorbid illnesses (AOR: 2.8, 95% CI: 1.5-5.0), DOTS not performed (AOR: 2.5, 95% CI: 1.4-4.5), chest radiography showing multiple lung lesions at first diagnosis (AOR: 3.0, 95% CI: 1.7-5.2), no chest radiography improvement in the first follow-up (AOR: 17.7, 95% CI: 8.2-38.0), and unknown status of chest radiography in the first follow-up (AOR: 48.1, 95% CI: 22.3-103.5). Health promotion and primary care should be implemented in the communities to achieve ultimate successful treatment.

Outcome Impacts Due to Pathogen-Specific Antimicrobial Resistance: A Narrative Review of Published Literature

Antimicrobial resistance (AMR) has become a global threat to not only public health impacts but also clinical and economic outcomes. During the past decades, there have been many studies focusing on surveillance, mechanisms, and diagnostics of AMR in infectious diseases but the impacts on public health, clinical and economic outcomes due to emergence of these AMRs are rarely studied and reported. This review was aimed to summarize the findings from published studies to report the outcome impacts due to AMR of malaria, tuberculosis and HIV and briefly discuss the implications for application to other infectious diseases. PubMed/Medline and Google Scholar databases were used for search of empirical and peer-reviewed papers reporting public health, clinical and economic outcomes due to AMR of malaria, tuberculosis and HIV. Papers published through 1 December 2019 were included in this review. A total of 76 studies were included for this review, including 16, 49 and 11 on public health, clinical and economic outcomes, respectively. The synthesized data indicated that the emergence and spread of AMR of malaria, tuberculosis and HIV have resulted in adverse public health, clinical and economic outcomes. AMR of malaria, tuberculosis and HIV results in significant adverse impacts on public health, clinical and economic outcomes. Evidence from this review suggests the needs to consider the similar studies for other infectious diseases.