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Said BN, Heysell SK, Yimer G, Aarnoutse RE, Kibiki GS, Mpagama S, Mbelele PM. Pharmacodynamic biomarkers for quantifying the mycobacterial effect of high doses of rifampin in patients with rifampin-susceptible pulmonary tuberculosis. Int J Mycobacteriol 2021; 10:457-462. [PMID: 34916467 PMCID: PMC7612567 DOI: 10.4103/ijmy.ijmy_178_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Suboptimal drug exposure in patients with drug-susceptible tuberculosis (DS-TB) can drive treatment failure. Pharmacodynamics (PD) biomarkers such as the plasma TB drug-activity (TDA) assay may guide dose finding studies and predict microbiological outcomes differently than conventional indices. Methods A study was nested from phase 2b randomized double-blind controlled trial of Tanzanian patients who received a 600 mg, 900 mg, or 1200 mg with a standard dose for DS-TB. Serum at 6 weeks collected over 24-h at 2-h intervals was collected for rifampin area under the concentration–time curve relative to minimum inhibitory concentration (AUC0-24/MIC) or peak concentration and MIC (Cmax/MIC). TDA was the ratio of time-to-positive growth of the patient’s Mycobacterium tuberculosis isolates with and without coculture of patient’s plasma collected at Cmax. Spearman’s rank correlation (r) between PD parameters and culture convention on both liquid and solid culture media. Results Among 10 patients, 600 mg (3), 900 mg (3), and 1200 mg (4) of rifampin dosages. The mean ± standard deviation (SD) of AUC0-24/MIC for patients on 600 mg was 168 ± 159 mg·h/L, on 900 mg was 169 ± 166 mg·h/L, and on 1200 mg was 308 ± 238 mg·h/L. The mean-TDA (SD) was 2.56 (±0.75), 1.5 (±0.59), and 2.29 (±1.08) for patients on 600 mg, 900 mg, and 1200 mg rifampin doses, respectively. Higher TDA values correlated with faster time to culture convention on both liquid (r =–0.55, P = 0.099) and solid media (r =–0.65, P = 0.04). Conclusions TDA and rifampin AUC0-24/MIC did not trend as expected with rifampin dose, but TDA better predicted the time to sputum culture conversion. TDA may provide additional discrimination in predicting treatment response for some regimens distinct from plasma exposure relative to MIC or mg/kg dose.
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Affiliation(s)
- Bibie N Said
- Kibong'oto Infectious Diseases Hospital (KIDH), Research Department, Siha, Kilimanjaro, Tanzania; Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Charlottesville, Virginia, USA
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Getnet Yimer
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Charlottesville, Virginia; Global One Health initiative, Office of International Affairs, The Ohio State University, Columbus, Ohio, USA
| | - Rob E Aarnoutse
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the, Netherlands
| | - Gibson S Kibiki
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Tumaini University, Moshi, Tanzania
| | - Stellah Mpagama
- Kibong'oto Infectious Diseases Hospital (KIDH), Research Department, Siha, Kilimanjaro, Tanzania
| | - Peter M Mbelele
- Kibong'oto Infectious Diseases Hospital (KIDH), Research Department, Siha, Kilimanjaro; Department of Global Health and Biomedical Sciences, School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
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Paleckyte A, Dissanayake O, Mpagama S, Lipman MC, McHugh TD. Reducing the risk of tuberculosis transmission for HCWs in high incidence settings. Antimicrob Resist Infect Control 2021; 10:106. [PMID: 34281623 PMCID: PMC8287104 DOI: 10.1186/s13756-021-00975-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 07/06/2021] [Indexed: 11/10/2022] Open
Abstract
Globally, tuberculosis (TB) is a leading cause of death from a single infectious agent. Healthcare workers (HCWs) are at increased risk of hospital-acquired TB infection due to persistent exposure to Mycobacterium tuberculosis (Mtb) in healthcare settings. The World Health Organization (WHO) has developed an international system of infection prevention and control (IPC) interventions to interrupt the cycle of nosocomial TB transmission. The guidelines on TB IPC have proposed a comprehensive hierarchy of three core practices, comprising: administrative controls, environmental controls, and personal respiratory protection. However, the implementation of most recommendations goes beyond minimal physical and organisational requirements and thus cannot be appropriately introduced in resource-constrained settings and areas of high TB incidence. In many low- and middle-income countries (LMICs) the lack of knowledge, expertise and practice on TB IPC is a major barrier to the implementation of essential interventions. HCWs often underestimate the risk of airborne Mtb dissemination during tidal breathing. The lack of required expertise and funding to design, install and maintain the environmental control systems can lead to inadequate dilution of infectious particles in the air, and in turn, increase the risk of TB dissemination. Insufficient supply of particulate respirators and lack of direction on the re-use of respiratory protection is associated with unsafe working practices and increased risk of TB transmission between patients and HCWs. Delayed diagnosis and initiation of treatment are commonly influenced by the effectiveness of healthcare systems to identify TB patients, and the availability of rapid molecular diagnostic tools. Failure to recognise resistance to first-line drugs contributes to the emergence of drug-resistant Mtb strains, including multidrug-resistant and extensively drug-resistant Mtb. Future guideline development must consider the social, economic, cultural and climatic conditions to ensure that recommended control measures can be implemented in not only high-income countries, but more importantly low-income, high TB burden settings. Urgent action and more ambitious investments are needed at both regional and national levels to get back on track to reach the global TB targets, especially in the context of the COVID-19 pandemic.
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Affiliation(s)
- Ana Paleckyte
- UCL Centre for Clinical Microbiology, Division of Infection & Immunity, UCL, London, UK
| | | | - Stella Mpagama
- Kibong'oto Infectious Diseases Hospital, Kilimanjaro, Tanzania
| | - Marc C Lipman
- UCL Respiratory, Division of Medicine, UCL, London, UK
| | - Timothy D McHugh
- UCL Centre for Clinical Microbiology, Division of Infection & Immunity, UCL, London, UK.
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Assemie MA, Alene M, Petrucka P, Leshargie CT, Ketema DB. Time to sputum culture conversion and its associated factors among multidrug-resistant tuberculosis patients in Eastern Africa: A systematic review and meta-analysis. Int J Infect Dis 2020; 98:230-236. [PMID: 32535296 DOI: 10.1016/j.ijid.2020.06.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/02/2020] [Accepted: 06/06/2020] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE This study aimed to consider the estimated time to multi-resistant tuberculosis culture conversion, and associated factors, in order to enhance evidence utilization in eastern Africa. METHODS We systematically identified available articles on multidrug-resistant tuberculosis culture conversion using PubMed, Scopus, Cochrane Library, Web of Science core collection, and Science Direct databases. A random-effects model was employed using the R 3.6.1 version and Stata/se 14 software. RESULTS Nine articles with a sample size of 2458 multidrug-resistant tuberculosis patients were included. The two-month culture conversion rate was 75.4%, with a median time of 61.2 days (interquartile range: 48.6-73.8). In the included studies, favorable treatment outcomes of MDR-TB patients were seen in 75% of the cases, while unfavorable treatment outcomes were seen in 18% (10% deaths, 7% defaulted, and 1% treatment failure) of the cases. The independent factor for delayed sputum culture conversion was body mass index below 18.5kg/m2 (HR=3.1, 95% CI: 2.0, 6.7). CONCLUSION The median time to sputum culture conversion was 61.2 days, which is a reasonably short time. Body mass index was the identified associated factor leading to delayed culture conversion. Therefore, there is a need for awareness of how to improve the nutritional status of multidrug-resistant tuberculosis patients through appropriate nutritional supports.
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Affiliation(s)
- Moges Agazhe Assemie
- Biostatstics Unit, Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia.
| | - Muluneh Alene
- Biostatstics Unit, Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia.
| | - Pammla Petrucka
- College of Nursing, University of Saskatchewan, Saskatoon, Canada; School of Life Sciences and Bioengineering, Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania.
| | - Cheru Tesema Leshargie
- Department of Environmental Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia.
| | - Daniel Bekele Ketema
- Biostatstics Unit, Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia.
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Mpagama SG. Diagnostic Opportunities for Optimizing Management of Multidrug-Resistant Tuberculosis (MDR-TB) in Tanzania. East Afr Health Res J 2018; 2:26-28. [PMID: 34308171 PMCID: PMC8279168 DOI: 10.24248/eahrj-d-16-00357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 03/08/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Tanzania is one of the countries confronting a multidrug-resistant tuberculosis (MDR-TB) epidemic. RESEARCH Research studies on drug susceptibility testing (DST) for second-line TB drugs given to Tanzanian MDR-TB patients has demonstrated mycobacterial resistance to important MDR-TB drugs, such as ethionamide, ofloxacin, amikacin, kanamycin, and pyrazinamide. Likewise, pharmacokinetic studies have shown a high frequency of patients with circulating serum drug levels below the expected ranges, especially for levofloxacin and kanamycin - key drugs in MDR-TB treatment that also affect ex-vivo plasma drug activity. RECOMMENDATIONS We suggest using molecular diagnostic assays, such as the GenoType MTBDRplus test, and inhA and/or katG genotypic results to optimize MDR-TB treatment. Quantitative drug susceptibility can guide the selection of options for second-line anti-TB drugs. The TB drug assay, an alternative biomarker for therapeutic drug monitoring, can identify patients who have extensively drug-resistant TB or are exposed to suboptimal serum drug levels of, specifically, levofloxacin and kanamycin.
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Gebreegziabher SB, Bjune GA, Yimer SA. Applying tuberculosis management time to measure the tuberculosis infectious pool at a local level in Ethiopia. Infect Dis Poverty 2017; 6:156. [PMID: 29137661 PMCID: PMC5686949 DOI: 10.1186/s40249-017-0371-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 10/20/2017] [Indexed: 11/28/2022] Open
Abstract
Background Measuring the size of the infectious pool of tuberculosis (TB) is essential to understand the burden and monitor trends of TB control program performance. This study applied the concept of TB management time to estimate and compare the size of the TB infectious pool between 2009 and 2014 in West Gojjam Zone of Amhara Region, Ethiopia. Methods New sputum smear-positive and smear-negative pulmonary TB (PTB) and retreatment cases who attended 30 randomly selected public health facilities in West Gojjam Zone from October 2013 to October 2014 were consecutively enrolled in the study. In order to determine the infectious period, the TB management time (number of days from the onset of cough until start of anti-TB treatment) was computed for each patient category. The number of undiagnosed TB cases was estimated and hence the TB management time for the undiagnosed category was calculated. The total size of the TB infectious pool during the study period for the study zone was estimated as the annual number of infectious person days. Results New smear-positive and smear-negative PTB cases contributed 25,050 and 12,931 infectious person days per year to the TB infectious pool, respectively. The retreatment and presently undiagnosed cases contributed 8840 and 34,310 infectious person days per year, respectively. The total size of the TB infectious pool in West Gojjam Zone during the study period was estimated at 81,131 infectious person days per year or 3405 infectious person days per 100,000 population per year. Compared to a similar study done in 2009 in the study area, the current study showed reduction of the TB infectious pool by 244,279 infectious person days. Conclusions TB management time is a simple and practical tool that may help to estimate and compare the changes in the size of the TB infectious pool at local level. It may also be used as an indicator to monitor the changes in TB control program performance. Electronic supplementary material The online version of this article (10.1186/s40249-017-0371-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Senedu Bekele Gebreegziabher
- Amhara Regional State Health Bureau, Bahir Dar, Ethiopia. .,Department of Community Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Gunnar Aksel Bjune
- Department of Community Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Solomon Abebe Yimer
- Amhara Regional State Health Bureau, Bahir Dar, Ethiopia.,Department of Community Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway.,Oslo University Hospital, Oslo, Norway.,Department of Bacteriology and Immunology, Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway
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Ebers A, Stroup S, Mpagama S, Kisonga R, Lekule I, Liu J, Heysell S. Determination of plasma concentrations of levofloxacin by high performance liquid chromatography for use at a multidrug-resistant tuberculosis hospital in Tanzania. PLoS One 2017; 12:e0170663. [PMID: 28141813 PMCID: PMC5283651 DOI: 10.1371/journal.pone.0170663] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 01/09/2017] [Indexed: 11/18/2022] Open
Abstract
Therapeutic drug monitoring may improve multidrug-resistant tuberculosis (MDR-TB) treatment outcomes. Levofloxacin demonstrates significant individual pharmacokinetic variability. Thus, we sought to develop and validate a high-performance liquid chromatography (HPLC) method with ultraviolet (UV) detection for levofloxacin in patients on MDR-TB treatment. The HPLC-UV method is based on a solid phase extraction (SPE) and a direct injection into the HPLC system. The limit of quantification was 0.25 μg/mL, and the assay was linear over the concentration range of 0.25—15 μg/mL (y = 0.5668x—0.0603, R2 = 0.9992) for the determination of levofloxacin in plasma. The HPLC-UV methodology achieved excellent accuracy and reproducibility along a clinically meaningful range. The intra-assay RSD% of low, medium, and high quality control samples (QC) were 1.93, 2.44, and 1.90, respectively, while the inter-assay RSD% were 3.74, 5.65, and 3.30, respectively. The mean recovery was 96.84%. This method was then utilized to measure levofloxacin concentrations from patients’ plasma samples from a retrospective cohort of consecutive enrolled subjects treated for MDR-TB at the national TB hospital in Tanzania during 5/3/2013–8/31/2015. Plasma was collected at 2 hours after levofloxacin administration, the time of estimated peak concentration (eCmax) treatment. Forty-one MDR-TB patients had plasma available and 39 had traceable programmatic outcomes. Only 13 (32%) patients had any plasma concentration that reached the lower range of the expected literature derived Cmax with the median eCmax being 5.86 (3.33–9.08 μg/ml). Using Classification and Regression Tree analysis, an eCmax ≥7.55 μg/mL was identified as the threshold which best predicted cure. Analyzing this CART derived threshold on treatment outcome, the time to sputum culture conversion was 38.3 ± 22.7 days vs. 47.8 ± 26.5 days (p = 0.27) and a greater proportion were cured, in 10 out of 15 (66.7%) vs. 6 out of 18 (33.3%) (p = 0.06) respectively. Furthermore, one patient with an eCmax/minimum inhibitory concentration (MIC) of only 1.13 acquired extensively drug resistant (XDR)-TB while undergoing treatment. The individual variability of levofloxacin concentrations in MDR-TB patients from Tanzania supports further study of the application of onsite therapeutic drug monitoring and MIC testing.
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Affiliation(s)
- Andrew Ebers
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, United States of America
| | - Suzanne Stroup
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, United States of America
| | - Stellah Mpagama
- Kibong'oto Infectious Disease Hospital, Kilimanjaro, Tanzania
| | - Riziki Kisonga
- Kibong'oto Infectious Disease Hospital, Kilimanjaro, Tanzania
| | - Isaack Lekule
- Kibong'oto Infectious Disease Hospital, Kilimanjaro, Tanzania
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, United States of America
| | - Scott Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, United States of America
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Sensititre MycoTB plate compared to Bactec MGIT 960 for first- and second-line antituberculosis drug susceptibility testing in Tanzania: a call to operationalize MICs. Antimicrob Agents Chemother 2015; 59:7104-8. [PMID: 26303804 DOI: 10.1128/aac.01117-15] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 08/20/2015] [Indexed: 11/20/2022] Open
Abstract
MIC testing for Mycobacterium tuberculosis is now commercially available. Drug susceptibility testing by the MycoTB MIC plate has not been directly compared to that by the Bactec MGIT 960. We describe a case of extensively drug-resistant tuberculosis (XDR-TB) in Tanzania where initial MIC testing may have prevented acquired resistance. From testing on archived isolates, the accuracy with the MycoTB plate was >90% for important first- and second-line drugs compared to that with the MGIT 960, and clinically useful quantitative interpretation was also provided.
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