Managing severe tuberculosis and its sequelae: from intensive care to surgery and rehabilitation

The clinical features and prognostic factors of miliary tuberculosis in a high tuberculosis burden area

BACKGROUND

Miliary Tuberculosis (TB) remains an important infectious disease that threatens human health. The clinical characteristics and prognostic factors of miliary TB are summarized in this study.

METHODS

The clinical information of miliary TB patients between 2010 and 2022 was retrospectively analyzed. Patients with miliary TB were characterized and compared to adverse outcomes cases. Factors independently associated with adverse outcomes were determined via multivariate logistic regression analysis.

RESULTS

A total of 288 patients were analyzed, including 181 with adverse outcomes. The clinical manifestations are atypical. 88.54% Of them experienced systemic symptoms, whilst 69.79% manifested respiratory symptoms. 40.97% Presented with neurologic symptoms, while 35.07% reported gastrointestinal symptoms. The major comorbidities were pharmacological immunosuppression (21.53%), pneumoconiosis (15.28%), diabetes (10.76%), and pregnancy or postpartum (7.29%). Regarding microbiology, most patients were diagnosed via sputum or Bronchoalveolar Lavage Fluid (BALF), pleural effusion, ascites, cerebrospinal fluid, urine TB-DNA, and tuberculosis culture. Meanwhile, 2.43% of patients were diagnosed via cerebrospinal fluid NGS. Independent risk factors predictive of adverse outcomes were current smoking, leukocytosis, elevated alanine aminotransferase (ALT) levels, and the combination of lymphopenia with bone marrow tuberculosis or tuberculous lymphadenitis. The accuracy of the model was validated by an area under the ROC curve of 0.753 (95% IC 0.697-0.810).

CONCLUSIONS

The clinical manifestations of miliary TB are atypical, and early diagnosis is challenging. The major comorbidities in miliary TB patients were pharmacological immunosuppression, pneumoconiosis, diabetes, pregnancy, and postpartum. Regarding etiological detection, multi-site and multi-type specimens should be collected for a timely diagnosis. Cerebrospinal fluid mNGS test may be a viable choice in some cases. Finally, current smoking, leukocytosis, elevated ALT levels, and the combination of lymphopenia with bone marrow tuberculosis or tuberculous lymphadenitis were identified as independent risk factors for adverse outcomes.

In vitro optimization of crushed drug-sensitive antituberculosis medication when administered via a nasogastric tube

IMPORTANCE

The incidence of tuberculosis (TB) in intensive care units (ICUs) can be as high as 3% in high-burden settings, translating to more than 7,500 patients admitted to the ICU annually. In resource-limited settings, the lack or absence of intravenous formulations of drug-sensitive antituberculosis medications necessitates healthcare practitioners to crush, dissolve, and administer the drugs to critically ill patients via a nasogastric tube (NGT). This off-label practice has been linked to plasma concentrations below the recommended target concentrations, particularly of rifampicin and isoniazid, leading to clinical failure and the development of drug resistance. Optimizing the delivery of crushed drug-sensitive antituberculosis medication via the NGT to critically ill patients is of utmost importance.

Brazilian Thoracic Association recommendations for the management of post-tuberculosis lung disease

Historically, all efforts against tuberculosis were focused on rapid diagnosis and effective treatment to break the chain of transmission of Mycobacterium tuberculosis. However, in the last few years, more and more evidence has been found on the dramatic consequences of the condition defined as post-tuberculosis lung disease (PTLD). Approximately one third of patients surviving pulmonary tuberculosis face considerable ongoing morbidities, including respiratory impairment, psychosocial challenges, and reduced health-related quality of life after treatment completion. Given the important global and local burden of tuberculosis, as well as the estimated burden of PTLD, the development of a consensus document by a Brazilian scientific society-Sociedade Brasileira de Pneumologia e Tisiologia (SBPT)-was considered urgent for the prevention and management of this condition in order to allocate resources to and within tuberculosis services appropriately and serve as a guide for health care professionals. A team of eleven pulmonologists and one methodologist was created by the SBPT to review the current evidence on PTLD and develop recommendations adapted to the Brazilian context. The expert panel selected the topics on the basis of current evidence and international guidelines. During the first phase, three panel members drafted the recommendations, which were divided into three sections: definition and prevalence of PTLD, assessment of PTLD, and management of PTLD. In the second phase, all panel members reviewed, discussed, and revised the recommendations until a consensus was reached. The document was formally approved by the SBPT in a special session organized during the 2023 SBPT Annual Conference.

Tuberculosis Severity Predictive Model Using Mtb Variants and Serum Biomarkers in a Colombian Cohort of APTB Patients

Currently, tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis (Mtb) that primarily affects the lungs. The severity of active pulmonary TB (APTB) is an important determinant of transmission, morbidity, mortality, disease experience, and treatment outcomes. Several publications have shown a high prevalence of disabling complications in individuals who have had severe APTB. Furthermore, certain strains of Mtb were associated with more severe disease outcomes. The use of biomarkers to predict severe APTB patients who are candidates for host-directed therapies, due to the high risk of developing post-tuberculous lung disease (PTLD), has not yet been implemented in the management of TB patients. We followed 108 individuals with APTB for 6 months using clinical tools, flow cytometry, and whole-genome sequencing (WGS). The median age of the study population was 26.5 years, and the frequency of women was 53.7%. In this study, we aimed to identify biomarkers that could help us to recognize individuals with APTB and improve our understanding of the immunopathology in these individuals. In this study, we conducted a follow-up on the treatment progress of 121 cases of APTB. The follow-up process commenced at the time of diagnosis (T0), continued with a control visit at 2 months (T2), and culminated in an exit appointment at 6 months following the completion of medical treatment (T6). People classified with severe APTB showed significantly higher levels of IL-6 (14.7 pg/mL; p < 0.05) compared to those with mild APTB (7.7 pg/mL) at T0. The AUCs for the ROC curves and the Matthews correlation coefficient values (MCC) demonstrate correlations ranging from moderate to very strong. We conducted WGS on 88 clinical isolates of Mtb, and our analysis revealed a total of 325 genes with insertions and deletions (Indels) within their coding regions when compared to the Mtb H37Rv reference genome. The pattern of association was found between serum levels of CHIT1 and the presence of Indels in Mtb isolates from patients with severe APTB. A key finding in our study was the high levels of CHIT1 in severe APTB patients. We identified a biomarker profile (IL-6, IFN-γ, IL-33, and CHIT1) that allows us to identify individuals with severe APTB, as well as the identification of a panel of polymorphisms (125) in clinical isolates of Mtb from individuals with severe APTB. Integrating these findings into a predictive model of severity would show promise for the management of APTB patients in the future, to guide host-directed therapy and reduce the prevalence of PTLD.

Practice patterns and trends in surgical treatment for chronic lung infections: a survey from the Brazilian Society of Thoracic Surgery

Background

Chronic lung infections represent a diversity of clinical entities that combined respond to significant public health, particularly in developing countries. However, there is no data regarding the practice patterns, surgeons' preferences, and technological usage, especially among Brazilian surgeons, in the setting of the surgical treatment of chronic lung infections. We, therefore, surveyed Brazilian thoracic surgeons from the Brazilian Society of Thoracic Surgery (SBCT) about practice patterns and trends in surgical treatment for chronic lung infections.

Methods

A cross-sectional anonymous survey of all thoracic surgeons from the Brazilian Society was conducted in 2019. As the study was purely descriptive no further statistical evaluation was performed.

Results

The responsive rate was 34% (259/766) from 23 of the 26 states in Brazil. A total of 141 (54.4%) participants reported their institution as a surgical reference for chronic infection lung disease, only 13.1% of surgeons have a high-volume service (more than 11 cases operated annually). The majority (76.2%) of respondents performed 1-5 surgical resection to treat tuberculosis (TB) sequelae, but only 62 (30.1%) had performed more than one resection to treat active TB. Chronic lung infection (76%) and hemoptysis (66%) were the most common symptoms as surgical indications. A proportion of 42.2% of the respondents do not have and/or perform routine drug sensitivity tests. In addition, 19.3% of respondents were not familiar with the recommendations of surgery in the treatment of pulmonary TB. Video-assisted thoracoscopic surgery (VATS) is available for 80% of respondents, while robotic surgery is for only 10%. Most (86%) surgeons have access to surgical staplers. Among the structural resources, respiratory isolation beds in the intensive care unit (ICU) (80%) and ward (79%) are frequently available resources. However, less than 12% of surgeons have in their institution a specific operating room for sputum-positive patients.

Conclusions

Lung resection for chronic infectious disease is an essential area of activity for thoracic surgeons in Brazil, which occurs mainly in the public sphere, with no concentration of cases per surgeon or institution. The lack of adequate resources in many centers justifies the creation of reference centers for improving care for these patients.

Post-tuberculosis lung disease and chronic obstructive pulmonary disease

ABSTRACT

The burden of chronic airway diseases, including chronic obstructive pulmonary disease (COPD), continues to increase, especially in low- and middle-income countries. Post-tuberculosis lung disease (PTLD) is characterized by chronic lung changes after the "cure" of pulmonary tuberculosis (TB), which may be associated with the pathogenesis of COPD. However, data on its prevalence, clinical manifestations, computed tomography features, patterns of lung function impairment, and influencing factors are limited. The pathogenic mechanisms underlying PTLD remain to be elucidated. This review summarizes the recent advances in PTLD and TB-associated COPD. Research is urgently needed both for the prevention and management of PTLD.

Disease burden of tuberculosis and post-tuberculosis in Inner Mongolia, China, 2016-2018 - based on the disease burden of post-TB caused by COPD

BACKGROUND

Tuberculosis (TB) remains one of the most serious infectious diseases worldwide. China has the second highest TB burden globally, but existing studies have mostly neglected the post-tuberculosis (post-TB) disease burden. This study estimated the disease burden of TB and post-TB in Inner Mongolia, China, from 2016 to 2018.

METHODS

Population data were collected from TB Information Management System. Post-TB disease burden was defined as the burden caused by Chronic Obstructive Pulmonary Disease (COPD) occurring after patients with TB were cured. To estimate the incidence rate of TB, standardized mortality rate, life expectancy, and cause eliminated life expectancy, using descriptive epidemiological, abridged life table and cause eliminated life table. On this basis, the Disability-Adjusted Life Years (DALY), Years Lived with Disability (YLD) and Years of Life Lost (YLL) due to TB were further be estimated. The data were analyzed using Excel 2016 and SPSS 26.0. Joinpoint regression models were used to estimate the time and age trends of the disease burden of TB and post-TB.

RESULTS

The TB incidence in 2016, 2017, and 2018 was 41.65, 44.30, and 55.63/100,000, respectively. The standardized mortality in the same period was 0.58, 0.65, and 1.08/100,000, respectively. From 2016 to 2018, the total DALYs of TB and post-TB were 5923.33, 6258.03, and 8194.38 person-years, and the DALYs of post-TB from 2016 to 2018 were 1555.89, 1663.33, and 2042.43 person-years. Joinpoint regression showed that the DALYs rate increased yearly from 2016 to 2018, and the rate of males was higher than that of females. TB and post-TB DALYs rates showed a rising tendency with increasing age (AAPC values were 149.6% and 157.0%, respectively, P < 0.05), which was higher in the working-age population and elderly.

CONCLUSION

The disease burden of TB and post-TB was heavy and increased year by year in Inner Mongolia from 2016 to 2018. Compared with the youngster and females, working-age population and the elderly and males had a higher disease burden. Policymakers should be paid more attention to the patients' sustained lung injury after TB cured. There is a pressing need to identify more effective measures for reducing the burden of TB and post-TB of people, to improve their health and well-being.

Drug resistant TB - latest developments in epidemiology, diagnostics and management

AIM

The aim of this review is to inform the reader on the latest developments in epidemiology, diagnostics and management.

EPIDEMIOLOGY

Drug-resistant Tuberculosis (DR-TB) continues to be a current global health threat, and is defined by higher morbidity and mortality, sequelae, higher cost and complexity. The WHO classifies drug-resistant TB into 5 categories: isoniazid-resistant TB, rifampicin resistant (RR)-TB and MDR-TB, (TB resistant to isoniazid and rifampicin), pre-extensively drug-resistant TB (pre-XDR-TB) which is MDR-TB with resistance to a fluoroquinolone and finally XDR-TB that is TB resistant to rifampicin, plus any fluoroquinolone, plus at least one further priority A drug (bedaquiline or linezolid). Of 500,000 estimated new cases of RR-TB in 2020, only 157 903 cases are notified. Only about a third of cases are detected and treated annually.

DIAGNOSTICS

Recently newer rapid diagnostic methods like the GeneXpert, whole genome sequencing and Myc-TB offer solutions for rapid detection of resistance.

TREATMENT

The availability of new TB drugs and shorter treatment regimens have been recommended for the management of DR-TB.

CONCLUSION

Despite advances in diagnostics and treatments we still have to find and treat two thirds of the drug resistant cases that go undetected and therefore go untreated each year. Control of TB and elimination will only occur if cases are detected, diagnosed and treated promptly.

History of prevention, diagnosis, treatment and rehabilitation of pulmonary sequelae of tuberculosis

Tuberculosis (TB), known as the White Plague' is of great significance to humanity for the magnitude of morbidity and mortality it has generated over centuries from the very start of human civilization. In this Review, we will describe the history of prevention (vaccination and management of TB infection), diagnosis, treatment and pulmonary rehabilitation of post-treatment sequelae. The article leads the reader through the main discoveries which paved the way to the modern approach to TB prevention and care. The history of Bacille Calmette-Guérin (BCG) vaccine and of the diagnosis and treatment of TB infection are presented, together with that of diagnosis and treatment of TB disease. Pivotal was in 1882 the discovery by Robert Koch of the aetiological agent of TB, and his pioneering work in culturing the bacillus and developing tuberculin. Also of enormous importance was, in 1895, the discovery of the X-rays by Wilhelm Conrad Röntgen, discovery which paved the way to the development of the modern imaging technologies. To complement this, the more recent history of rehabilitation of post-treatment sequelae is summarized, given the importance this issue has on patients' wellbeing and Quality of Life.

Systemic inflammatory changes and their clinical implications following thoracic cancer surgery

Trauma that follows every surgical procedure triggers an inflammatory response, which in the majority of the cases reflects the associated tissue damage. Tissue regeneration, postoperative outcomes, and systemic antibacterial activity are highly dependent on the initial inflammatory response elicited by surgical trauma. More specifically, in thoracic surgery, systemic cytokine and cellular changes have an impact on several measured postoperative outcomes. Lastly, the introduction of video-assisted and robotic-assisted thoracic surgery has been shown to provide improved postoperative outcomes with altered systemic inflammatory response, when compared to open thoracic surgery. This review outlines the major systemic inflammatory changes observed in thoracic cancer surgery as well as its clinical significance.

Breathing Back Better! A State of the Art on the Benefits of Functional Evaluation and Rehabilitation of Post-Tuberculosis and Post-COVID Lungs

Currently, tuberculosis (TB) and COVID-19 account for substantial morbidity and mortality worldwide, not only during their acute phase, but also because of their sequelae. This scoping review aims to describe the specific aspects of post-TB and post-COVID (long-COVID-19) sequelae, and the implications for post-disease follow-up and rehabilitation. In particular, evidence on how to identify patients affected by sequelae is presented and discussed. A section of the review is dedicated to identifying patients eligible for pulmonary rehabilitation (PR), as not all patients with sequelae are eligible for PR. Components of PR are presented and discussed, as well as their effectiveness. Other essential components to implement comprehensive rehabilitation programmes such as counselling and health education of enrolled patients, evaluation of cost-effectiveness of PR and its impact on health systems as well as research priorities for the future are included in this scoping review.

Post-tuberculosis lung disease: a comparison of Brazilian, Italian, and Mexican cohorts

OBJECTIVE

To evaluate lung function in a cohort of patients with a history of pulmonary tuberculosis in Brazil, as well as to evaluate the decline in lung function over time and compare it with that observed in similar cohorts in Mexico and Italy.

METHODS

The three cohorts were compared in terms of age, smoking status, pulmonary function test results, six-minute walk test results, and arterial blood gas results. In the Brazilian cohort, pulmonary function test results, six-minute walk test results, and arterial blood gas results right after the end of tuberculosis treatment were compared with those obtained at the end of the follow-up period.

RESULTS

The three cohorts were very different regarding pulmonary function test results. The most common ventilatory patterns in the Brazilian, Italian, and Mexican cohorts were an obstructive pattern, a mixed pattern, and a normal pattern (in 58 patients [50.9%], in 18 patients [41.9%], and in 26 patients [44.1%], respectively). Only 2 multidrug-resistant tuberculosis cases were included in the Brazilian cohort, whereas, in the Mexican cohort, 27 cases were included (45.8%). Mean PaO2 and mean SaO2 were lower in the Mexican cohort than in the Brazilian cohort (p < 0.0001 and p < 0.002 for PaO2 and SaO2, respectively). In the Brazilian cohort, almost all functional parameters deteriorated over time.

CONCLUSIONS

This study reinforces the importance of early and effective treatment of drug-susceptible tuberculosis patients, because multidrug-resistant tuberculosis increases lung damage. When patients complete their tuberculosis treatment, they should be evaluated as early as possible, and, if post-tuberculosis lung disease is diagnosed, they should be managed and offered pulmonary rehabilitation because there is evidence that it is effective in these patients.

Pulmonary tuberculosis in intensive care setting, with a focus on the use of severity scores, a multinational collaborative systematic review

Background and aim

Tuberculosis (TB) is associated with a high mortality in the intensive care unit (ICU), especially in subjects with Acute Respiratory Distress Syndrome (ARDS) requiring mechanical ventilation. Despite its global burden on morbidity and mortality, TB is an uncommon cause of ICU admission, however mortality is disproportionate to the advances in diagnosis and treatment made. Herein we report a systematic review of published studies.

Methods

Our Literature search was conducted to identify studies on outcomes of individuals with TB admitted to ICU. We report and review in-hospital mortality, predictors of poorer outcomes, usefulness of severity scoring systems and potential benefits of intravenous antibiotics. Searches from Pubmed, Embase, Cochrane and Medline were conducted from inception to March 2020. Only literature in English was included.

Results

Out of 529 potentially relevant articles, 17 were included. Mortality across all studies ranged from 29-95% with an average of 52.9%. All severity scores underestimated average mortality. The most common indication for ICU admission was acute respiratory failure (36.3%). Negative predictors of outcome included hospital acquired infections, need of mechanical ventilation and vasopressors, delay in initiation of anti-TB treatment, more than one organ failure and a higher severity score. Low income, high incidence countries showed a 23.4% higher mortality rate compared to high income, low TB incidence countries.

Conclusion

Mortality in individuals with TB admitted to ICU is high. Earlier detection and treatment initiation is needed.

Clinical standards for the assessment, management and rehabilitation of post-TB lung disease

BACKGROUND: Increasing evidence suggests that post-TB lung disease (PTLD) causes significant morbidity and mortality. The aim of these clinical standards is to provide guidance on the assessment and management of PTLD and the implementation of pulmonary rehabilitation (PR).METHODS: A panel of global experts in the field of TB care and PR was identified; 62 participated in a Delphi process. A 5-point Likert scale was used to score the initial ideas for standards and after several rounds of revision the document was approved (with 100% agreement).RESULTS: Five clinical standards were defined: Standard 1, to assess patients at the end of TB treatment for PTLD (with adaptation for children and specific settings/situations); Standard 2, to identify patients with PTLD for PR; Standard 3, tailoring the PR programme to patient needs and the local setting; Standard 4, to evaluate the effectiveness of PR; and Standard 5, to conduct education and counselling. Standard 6 addresses public health aspects of PTLD and outcomes due to PR.CONCLUSION: This is the first consensus-based set of Clinical Standards for PTLD. Our aim is to improve patient care and quality of life by guiding clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage PTLD.

Effect of Health Education Combined with Dietary Guidance on Nutritional Indicator, Immune Level, and Quality of Life of Patients with Pulmonary Tuberculosis

OBJECTIVE

To investigate the effects of health education combined with dietary guidance on nutritional indicators, immune level, and quality of life of patients with pulmonary tuberculosis.

METHOD

A total of 123 patients with pulmonary tuberculosis who were hospitalized to our hospital between October 2019 and October 2020 were chosen for the study and were separated into 60 control cases and 63 observation cases based on the ward they were assigned to. Patients in the two groups were compared in terms of nutritional risk, nutritional indicator levels in serum, immunological function, treatment compliance, sputum culture conversion rate, and quality of life.

RESULT

With the prolongation of patients' illness, the total NRS 2002 score gradually increased in both groups and the total NRS 2002 score of patients in the control group was higher than that of patients in the observation group at the same time point after discharge. The difference between the total NRS 2002 score of patients in both groups was significant at 3 and 6 months after discharge. After the intervention, the Hb, ALB, CD4+, and CD4+/CD8+ levels of patients in both groups were higher than those at the time of admission, and the CD8+ levels were lower than those at the time of admission. At 6 months after discharge, the Hb, ALB, CD4+, and CD4+/CD8+ levels of patients in the observation group were significantly higher than those in the control group, and the CD8+ levels were significantly lower than those in the control group. The treatment compliance rate of patients in the observation group (96.83%) was significantly higher than that of the control group (75%), and the negative sputum culture transfer rate (85.71%) was significantly higher than that in the control group (60%). The overall quality of life scores of patients in the observation group was significantly higher than that in the control group.

CONCLUSION

Health education combined with dietary guidance for patients with pulmonary tuberculosis can deepen patients' understanding of disease and nutritional knowledge, improve treatment compliance, improve their nutritional status, enhance their immune function, accelerate sputum bacterial conversion, enhance treatment effect, and improve their quality of life.

Persistent chronic respiratory symptoms despite TB cure is poorly correlated with lung function

BACKGROUND: Persistent respiratory symptoms and lung function deficits are common after patients with TB. We aimed to define the burden of post-TB lung disease (PTLD) and assess associations between symptoms and impairment in two high TB incidence communities.METHODS: This was a cross-sectional survey of adults in Cape Town, South Africa who completed TB treatment 1-5 years previously. Questionnaires, spirometry and 6-minute walking distance (6MWD) were used to assess relationships between outcome measures and associated factors.RESULTS: Of the 145 participants recruited (mean age: 42 years, range: 18-75; 55 [38%] women), 55 (38%) had airflow obstruction and 84 (58%) had low forced vital capacity (FVC); the mean 6MWD was 463 m (range: 240-723). Respiratory symptoms were common: chronic cough (n = 27, 19%), wheeze (n = 61, 42%) and dyspnoea (modified MRC dyspnoea score 3 or 4: n = 36, 25%). There was poor correlation between FVC or obstruction and 6MWD. Only low body mass index showed consistent association with outcomes on multivariable analyses. Only 19 (13%) participants had a diagnosis of respiratory disease, and 16 (11%) currently received inhalers.CONCLUSION: There was substantial burden of symptoms and physiological impairment in this "cured" population, but poor correlation between objective outcome measures, highlighting deficits in our understanding of PTLD.

Outcome of treatment of MDR-TB or drug-resistant patients treated with bedaquiline and delamanid: Results from a large global cohort

The World Health Organization (WHO) recommends countries introduce new anti-TB drugs in the treatment of multidrug-resistant tuberculosis. The aim of the study is to prospectively evaluate the effectiveness of bedaquiline (and/or delamanid)- containing regimens in a large cohort of consecutive TB patients treated globally. This observational, prospective study is based on data collected and provided by Global Tuberculosis Network (GTN) centres and analysed twice a year. All consecutive patients (including children/adolescents) treated with bedaquiline and/or delamanid were enrolled, and managed according to WHO and national guidelines. Overall, 52 centres from 29 countries/regions in all continents reported 883 patients as of January 31st 2021, 24/29 countries/regions providing data on 100% of their consecutive patients (10-80% in the remaining 5 countries). The drug-resistance pattern of the patients was severe (>30% with extensively drug-resistant -TB; median number of resistant drugs 5 (3-7) in the overall cohort and 6 (4-8) among patients with a final outcome). For the patients with a final outcome (477/883, 54.0%) the median (IQR) number of months of anti-TB treatment was 18 (13-23) (in days 553 (385-678)). The proportion of patients achieving sputum smear and culture conversion ranged from 93.4% and 92.8% respectively (whole cohort) to 89.3% and 88.8% respectively (patients with a final outcome), a median (IQR) time to sputum smear and culture conversion of 58 (30-90) days for the whole cohort and 60 (30-100) for patients with a final outcome and, respectively, of 55 (30-90) and 60 (30-90) days for culture conversion. Of 383 patients treated with bedaquiline but not delamanid, 284 (74.2%) achieved treatment success, while 25 (6.5%) died, 11 (2.9%) failed and 63 (16.5%) were lost to follow-up.

Integrating Pharmacokinetics and Pharmacodynamics in Operational Research to End Tuberculosis

Tuberculosis (TB) elimination requires innovative approaches. The new Global Tuberculosis Network (GTN) aims to conduct research on key unmet therapeutic and diagnostic needs in the field of TB elimination using multidisciplinary, multisectorial approaches. The TB Pharmacology section within the new GTN aims to detect and study the current knowledge gaps, test potential solutions using human pharmacokinetics informed through preclinical infection systems, and return those findings to the bedside. Moreover, this approach would allow prospective identification and validation of optimal shorter therapeutic durations with new regimens. Optimized treatment using available and repurposed drugs may have an increased impact when prioritizing a person-centered approach and acknowledge the importance of age, gender, comorbidities, and both social and programmatic environments. In this viewpoint article, we present an in-depth discussion on how TB pharmacology and the related strategies will contribute to TB elimination.

[The treatment of tuberculosis under current conditions]

AIM

Study of the current state of problems of treatment of patients with tuberculosis based on literature data and their own experience.

MATERIALS AND METHODS

In the Russian Federation, the number and proportion of patients with co-infection with HIV/tuberculosis continues to increase against the background of improvement in the main epidemiological indicants for tuberculosis. In 2017, 20.9% of newly diagnosed tuberculosis patients had HIV infection. The combination of the two infections significantly complicates the further improvement of the situation with tuberculosis, and the appearance of drug-resistant strains of Mycobacterium tuberculosis sometimes completely neutralizes the results of chemotherapy. The article describes the schemes of modern tuberculosis chemotherapy taking into account HIV/tuberculosis co-infection, as well as MDR in combination with surgical treatment methods, as well as analyzes the data of epidemiological monitoring of treatment of 1115 tuberculosis patients newly diagnosed in 2017 in Moscow, 360 tuberculosis patients with MDR MBT (cohort 20132014), the results of treatment with the use of new chemotherapy regimens for tuberculosis (bedaquiline, linezolid, moxifloxacin) in 36 patients, the effectiveness and safety of surgical methods in 192 patients.

RESULTS

The application of new individualized anti-TB chemotherapy schedules in patients with HIV co-infection/tuberculosis with MDR-MBT has allowed to improve the treatment efficacy. The surgical intervention combined with modern chemotherapy regimens in patients with HIV/tuberculosis co-infection with MDR MBT has been proved to be effective and safe, contributes to the improving the results of treatment for this category of patients.

CONCLUSION

The confluence of two global problems of co-infection HIV/TB and MDR TB, significantly prevents from the end of the tuberculosis epidemic in the world. At the same time, advances in the development and implementation of new anti-TB drugs and surgical treatment methods give hope for significant progress for resolving this situation.

Post-Tuberculosis (TB) Treatment: The Role of Surgery and Rehabilitation

Even though the majority of tuberculosis (TB) programmes consider their work completed when a patient is ‘successfully’ cured, patients often continue to suffer with post-treatment or surgical sequelae. This review focuses on describing the available evidence with regard to the diagnosis and management of post-treatment and surgical sequelae (pulmonary rehabilitation). We carried out a non-systematic literature review based on a PubMed search using specific key-words, including various combinations of ‘TB’, ‘MDR-TB’, ‘XDR-TB’, ‘surgery’, ‘functional evaluation’, ‘sequelae’ and ‘pulmonary rehabilitation’. References of the most important papers were retrieved to improve the search accuracy. We identified the main areas of interest to describe the topic as follows: 1) ‘Surgery’, described through observational studies and reviews, systematic reviews and meta-analyses, IPD (individual data meta-analyses), and official guidelines (GRADE (Grading of Recommendations Assessment, Development and Evaluation) or not GRADE-based); 2) Post-TB treatment functional evaluation; and 3) Pulmonary rehabilitation interventions. We also highlighted the priority areas for research for the three main areas of interest. The collection of high-quality standardized variables would allow advances in the understanding of the need for, and effectiveness of, pulmonary rehabilitation at both the individual and the programmatic level. The initial evidence supports the importance of the adequate functional evaluation of these patients, which is necessary to identify those who will benefit from pulmonary rehabilitation.

MDR/XDR-TB management of patients and contacts: Challenges facing the new decade. The 2020 clinical update by the Global Tuberculosis Network

The continuous flow of new research articles on MDR-TB diagnosis, treatment, prevention and rehabilitation requires frequent update of existing guidelines. This review is aimed at providing clinicians and public health staff with an updated and easy-to-consult document arising from consensus of Global Tuberculosis Network (GTN) experts. The core published documents and guidelines have been reviewed, including the recently published MDR-TB WHO rapid advice and ATS/CDC/ERS/IDSA guidelines. After a rapid review of epidemiology and risk factors, the clinical priorities on MDR-TB diagnosis (including whole genome sequencing and drug-susceptibility testing interpretations) and treatment (treatment design and management, TB in children) are discussed. Furthermore, the review comprehensively describes the latest information on contact tracing and LTBI management in MDR-TB contacts, while providing guidance on post-treatment functional evaluation and rehabilitation of TB sequelae, infection control and other public health priorities.

Surveillance of adverse events in the treatment of drug-resistant tuberculosis: first global report

The World Health Organization (WHO) recommends that countries implement pharmacovigilance and collect information on active drug safety monitoring (aDSM) and management of adverse events.The aim of this prospective study was to evaluate the frequency and severity of adverse events to anti-tuberculosis (TB) drugs in a cohort of consecutive TB patients treated with new (i.e. bedaquiline, delamanid) and repurposed (i.e. clofazimine, linezolid) drugs, based on the WHO aDSM project. Adverse events were collected prospectively after attribution to a specific drug together with demographic, bacteriological, radiological and clinical information at diagnosis and during therapy. This interim analysis included patients who completed or were still on treatment at time of data collection.Globally, 45 centres from 26 countries/regions reported 658 patients (68.7% male, 4.4% HIV co-infected) treated as follows: 87.7% with bedaquiline, 18.4% with delamanid (6.1% with both), 81.5% with linezolid and 32.4% with clofazimine. Overall, 504 adverse event episodes were reported: 447 (88.7%) were classified as minor (grade 1-2) and 57 (11.3%) as serious (grade 3-5). The majority of the 57 serious adverse events reported by 55 patients (51 out of 57, 89.5%) ultimately resolved. Among patients reporting serious adverse events, some drugs held responsible were discontinued: bedaquiline in 0.35% (two out of 577), delamanid in 0.8% (one out of 121), linezolid in 1.9% (10 out of 536) and clofazimine in 1.4% (three out of 213) of patients. Serious adverse events were reported in 6.9% (nine out of 131) of patients treated with amikacin, 0.4% (one out of 221) with ethionamide/prothionamide, 2.8% (15 out of 536) with linezolid and 1.8% (eight out of 498) with cycloserine/terizidone.The aDSM study provided valuable information, but implementation needs scaling-up to support patient-centred care.

Effectiveness of pulmonary rehabilitation in severe asthma: a retrospective data analysis

Background: Pulmonary Rehabilitation (PR) is a multimodal treatment that is still poorly investigated in severe asthma where respiratory symptoms remain "uncontrolled" despite intensive pharmacological therapy. Bronchiectasis and obstructive sleep apnea (OSAS) are common comorbidities which may worsen asthma control.Aim: Aim of the present study is to investigate the effectiveness of PR on functional exercise, dyspnea, and muscle fatigue in patients with severe asthma.Methods: A total of 317 patients affected from severe asthma according to GINA guidelines who underwent a multidisciplinary 3 weeks rehabilitation program with an adherence of >80% to PR and able to complete a Six Minute Walking Test (6MWT) were retrospectively included in the analysis. Pulmonary rehabilitation included endurance training, educational meetings, chest physiotherapy, breathing exercises, and psychological support. Six-minute walking distance and Borg scale for dyspnea and muscle fatigue were recorded before and after the rehabilitation.Results: A total of 371 patients were analyzed, 39 had bronchiectasis (10.5%), 163 (43.9%) OSAS and 17 had both (4.6%). PR significantly improved 6MWT distance, Borg dyspnea and muscle fatigue (p value < 0.0001 for all outcomes) and mean SpO2 recorded during 6MWT (p value < 0.0001). Median (IQR) delta 6 minute walking distance was 33 (14-60) m. 6MWT distance (p < 0.0001) and the oxygen saturation (p < 0.01) significantly improved in severe asthma with bronchiectasis and/or OSAS.Conclusions: Our study provides evidence for the first time on a large sample of patients with severe asthma that a multidisciplinary PR program is effective in terms of exercise capacity and symptoms. In addition, exercise capacity improved in the presence of bronchiectasis and/or OSAS.