Treatment Outcomes in Global Systematic Review and Patient Meta-Analysis of Children with Extensively Drug-Resistant Tuberculosis

Tuberculosis parenteral therapeutic regimens for critical patients or non-functional intestinal tract: Brief review and proposal of protocol

Standard anti-tuberculosis regimens (Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol [RHZE]) remain challenging for critically ill patients and those with a non-functioning gastrointestinal tract. In Brazil, these challenges are amplified by the lack of Intravenous (IV) rifampicin, isoniazid, and ethambutol, which often results in suboptimal outcomes. This brief communication synthesized evidence on parenteral therapies and proposed a structured, five-step protocol for critically ill patients unable to receive oral drugs. A narrative review of the guidelines and key studies was also conducted. IV formulations of RHZE are approved in only some countries and are not available everywhere. Alternative IV drug classes, such as fluoroquinolones, aminoglycosides, carbapenems, and oxazolidinones, can address malabsorption or intolerance to oral RHZE. However, no standardized regimen exists for this population. Our five-step protocol advises: (1) Characterizing each TB case, (2) determining IV necessity, (3) Consulting specialized TB services, (4) Designing a safe and effective regimen, and (5) Re-evaluating therapy for transition to oral treatment. Given the morbidity and mortality from severe TB in Intensive Care Units (ICU), a formalized approach is essential. Further research and policy initiatives regarding IV first-line drugs are crucial to improve treatment outcomes in this vulnerable group. This strategy unifies practice across diverse clinical settings.

Treatment outcomes among children and adolescents with extensively drug-resistant (XDR) and pre-XDR tuberculosis: Systematic review and meta-analysis

Extensively drug-resistant (XDR) and pre-XDR- tuberculosis (TB) account for approximately a third of pediatric MDR-TB cases globally. Clinical management is challenging; recommendations are based on limited evidence. We assessed the clinical outcomes for children and adolescents treated for XDR-and pre-XDR-TB. We performed a systematic review and meta-analysis of published studies reporting treatment outcomes for children and adolescents with XDR-and pre-XDR-TB. MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and trial registries up to 31 December 2023 were searched. Eligible studies included children and adolescents aged <18 years with XDR-or pre-XDR-TB. The primary outcome was treatment success, defined as a composite of cure and treatment completion. Secondary outcomes were death, failure/ lost to follow-up and adverse events. We identified 34 population-based studies and 14 case studies, which reported treatment outcomes for a total of 656 patients. Treatment durations ranged from 6 to 27 months; follow-up after treatment completion ranged from 2 months to 4 years. The pooled estimate for treatment success in XDR-and pre-XDR-TB was 88·9% (95%CI: 59·7-100%) and 65·4% (95%CI: 27·7-100%), respectively. Drug adverse effects were reported in 56.4% (95%CI: 9.9-100%) and 68.2% (95%CI: 0-100%) of children respectively. Few childhood XDR- and pre-XDR-TB cases are reported. The relatively good treatment outcomes in children compared to adults may be partly due to publishing bias. Drug adverse effects are common.

Pediatric Drug-Resistant Tuberculosis: The Current and Future Prospects for Management and Prevention

In the continued battle against one of the oldest enemies known to mankind, Mycobacterium tuberculosis (MTB), the emergence of drug resistance to antituberculosis drugs among children poses multiple challenges for early detection and treatment. Molecular diagnostics and newer drugs like bedaquiline and delamanid have strengthened the armamentarium and helped design convenient, safe, and child-friendly therapeutic regimens against drug-resistant tuberculosis (TB). Preventive strategies like treatment of TB infection among children living in close contact with patients with drug-resistant TB and effective vaccines against TB are currently in the investigative stages of development and implementation. In addition to the implementation of recent novel diagnostics and treatment modalities, effective psychosocial and nutritional support, as well as dedicated monitoring for compliance and adverse effects, are crucial determinants for successful treatment outcomes in these children.

Gastroesophageal variceal hemorrhage in patients with chronic liver diseases attending university of Gondar Specialized comprehensive hospital in Ethiopia: Institutional based cross-sectional study

Introduction

Rupture and bleeding from Gastroesophageal Varices (GEVs) are major complications among patients with chronic liver disease (CLD) and are associated with a high mortality rate. Hence, identifying factors of Gastroesophageal Variceal Hemorrhage (GEVH) is essential for the management and prevention of this fatal outcome.

Objective

To assess the prevalence of GEVH and its associated factors among patients with CLD in Northwest Ethiopia.

Methods

An institutional based cross-sectional study design was employed on a total of 262 patients. The data was entered into Epi-Data version 3.1, and then exported and analyzed using STATA version 14. The distribution of variables was checked using kolmogorov-smirnov test. Bivariable logistic regression model was fitted to select variables for multivariable analysis. In the final model, adjusted odds ratio with 95% confidence level and P-value less than 0.05 were used to assess degree of association.

Results

The mean age of the study subjects was found to be 37.76 years (SD ± 11.62). The prevalence of GEVH was found to be 52% (95% CI: 49.6-54.2). Patients with grade F2 and F3 varices have 3.41 times (AOR: 3.41, 95% CI: 2.33-4.74) and 3.33 times (AOR: 3.33, 95% CI: 2.55-4.12) higher odds of bleeding, respectively. Patients not taking beta blocker have 2.38 times (AOR: 2.38, 95% CI: 1.82-3.90) increased odds of bleeding. Patients with more than three years of duration of illness have 2 times (AOR: 2.19, 95% CI: 1.39-3.99) increased odds of bleeding. Patients with platelet number less than 50,000/μl have 3.46 times (AOR: 3.46, 95% CI: 2.55-4.17) higher odds of bleeding.

Conclusion

GEVH is found to be high in patients with CLD seen at university of Gondar Hospital. Higher grade of varices, non-use of beta blockers, presence of infection, platelet number and age are associated with higher occurrence of bleeding, pointing the possibility of averting this fatal complication, for most of the identified factors are preventable.

Treatment Outcomes Among Pregnant Patients With Multidrug-Resistant Tuberculosis: A Systematic Review and Meta-analysis

IMPORTANCE

The management of multidrug-resistant tuberculosis (MDR-TB) during pregnancy is challenging, yet no systematic synthesis of evidence has accurately measured treatment outcomes.

OBJECTIVE

To systematically synthesize treatment outcomes and adverse events among pregnant patients with MDR-TB.

DATA SOURCES

PubMed, Scopus, Web of Science, and ProQuest were searched from the inception of each database through August 31, 2021.

STUDY SELECTION

Studies containing cohorts of pregnant patients with a defined treatment outcome were eligible.

DATA EXTRACTION AND SYNTHESIS

Independent reviewers screened studies and assessed the risk of bias. The study followed the Preferring Reporting Items for Systematic Review and Meta-analyses reporting guideline. Meta-analysis was performed using random-effects models. The sources of heterogeneity were explored through metaregression.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of patients with each treatment outcome (including treatment success, death, loss to follow-up, and treatment failure), and the secondary outcomes included the proportion of patients experiencing adverse events during pregnancy.

RESULTS

In this systematic review and meta-analysis, 10 studies containing 275 pregnant patients with available data on treatment outcomes were included. The pooled estimate was 72.5% (95% CI, 63.3%-81.0%) for treatment success, 6.8% (95% CI, 2.6%-12.4%) for death, 18.4% (95% CI, 13.1%-24.2%) for loss to follow-up, and 0.6% (95% CI, 0.0%-2.9%) for treatment failure. Treatment success was significantly higher in studies in which the proportion of patients taking linezolid was greater than the median (20.1%) compared with studies in which this proportion was lower than the median (odds ratio, 1.22; 95% CI, 1.05-1.42). More than half of the pregnant patients (54.7%; 95% CI, 43.5%-65.4%) experienced at least 1 type of adverse event, most commonly liver function impairment (30.4%; 95% CI, 17.7%-45.7%), kidney function impairment (14.9%; 95% CI, 6.2%-28.3%), hypokalemia (11.9%; 95% CI, 3.9%-25.6%), hearing loss (11.8%; 95% CI, 5.5%-21.3%), gastrointestinal disorders (11.8%; 95% CI, 5.2%-21.8%), psychiatric disorders (9.1%; 95% CI, 2.5%-21.6%), or anemia (8.9%; 95% CI, 3.6%-17.4%). The pooled proportion of favorable pregnancy outcomes was 73.2% (95% CI, 49.4%-92.1%). The most common types of adverse pregnancy outcomes were preterm birth (9.5%; 95% CI, 0.0%-29.0%), pregnancy loss (6.0%; 95% CI, 1.3%-12.9%), low birth weight (3.9%; 95% CI, 0.0%-18.7%), and stillbirth (1.9%; 95% CI, 0.1%-5.1%). Most of the studies had low-quality (3 studies) or medium-quality (4 studies) scores.

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, high treatment success and favorable pregnancy outcomes were reported among pregnant patients with MDR-TB. Further research is needed to design shorter, more effective, and safer treatment regimens for pregnant patients with MDR-TB.

Research Questions and Priorities for Pediatric Tuberculosis: A Survey of Published Systematic Reviews and Meta-Analyses

Background. Advancing a research agenda designed to meet the specific needs of children is critical to ending pediatric TB epidemic. Systematic reviews are increasingly informing policies in pediatric tuberculosis (TB) care and control. However, there is a paucity of information on pediatric TB research priorities. Methodology. We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library for systematic reviews and meta-analyses on any aspect related to pediatric TB published between 2015 and 2021. We used the UK Health Research Classification System (HRCS) to help us classify the research questions and priorities. Findings. In total, 29 systematic reviews, with 84 research questions, were included in this review. The four most common research topics in the area of detection were 43.33% screening and diagnosis of TB, 23.33% evaluation of treatments and therapeutic interventions, 13.34% TB etiology and risk factors, and 13.34% prevention of disease and conditions and promotion of well-being. The research priorities focused mainly on evaluating TB diagnosis by improving yield through enhanced in specimen collection or preparation and evaluating of bacteriological TB diagnostic tests. Other topics of future research were developing a treatment for TB in children, assessing the use of IPT in reducing TB-associated morbidity, evaluating the prioritization of an IPT-friendly healthcare environment, and providing additional guidance for the use of isoniazid in the prevention of TB in HIV-infected children. Conclusion. There is a need for more systematic reviews on pediatric TB. The review identified several key priorities for future pediatric TB research mainly in the domain of (1) “Detection, screening and diagnosis,” “Development of Treatments and Therapeutic Interventions,” and “Prevention of Disease and Conditions, and Promotion of Well-Being.” These domains are very relevant in the research component of the roadmap towards ending TB in children. It also will serve as an additional action in the WHO End TB strategy.

Treatment outcomes among childhood extensively drug-resistant tuberculosis patients in Pakistan

Extensively drug-resistant (XDR) tuberculosis (TB), previously defined as that caused by Mycobacterium tuberculosis concurrently resistant to isoniazid, rifampicin, any fluoroquinolone (FQ) and at least one of the three second-line injectable (SLI) drugs (amikacin, kanamycin and capreomycin), is now defined as TB caused by M. tuberculosis concurrently resistant to isoniazid, rifampicin, any FQ and at least one additional group A drug (levofloxacin, moxifloxacin, bedaquiline and linezolid) [1, 2]. It is the most difficult to treat form of TB, with an overall treatment success rate ranging from 4% to 65% [3]. Like other forms of TB, XDR-TB affects people irrespective of their age, including children (age<14 years). Although children suffering from drug-resistant (DR)-TB have a diverse spectrum of disease and adverse events, and different psychosocial, developmental and educational needs than adults, still they are treated with the same regimen as that of the adult DR-TB patients. The previously conducted, very few studies among childhood XDR-TB patients (sample size ranged from eight to 37 patients) have reported a variable rate of successful treatment outcomes (81–100%) [4, 5]. Despite Pakistan being a high DR-TB burden country, initiation of programmatic management of DR-TB (PMDT) back in 2010 [6] and >30 PMDT units all over the country [3], there was a lack of information about treatment outcomes of childhood XDR-TB patients that country. Thus, this study was conducted to evaluate the treatment outcomes among childhood XDR-TB patients in Pakistan.

Treatment outcomes of childhood XDR-TB patients in Pakistan are better than in adult patients but still disappointinghttps://bit.ly/3rkQ9sw

Two cases of pre-extensively drug resistant tuberculosis in children in Indonesia

Few reports are available on children with pre-extensively drug-resistant tuberculosis (pre-XDR-TB), which is defined as Mycobacterium tuberculosis resistant to both isoniazid and rifampicin plus resistance to either a fluoroquinolone or a second-line injectable drug. Pre-XDR-TB treatment for children usually has been individualized based on drug susceptibility test (DST) results, but treatment remains challenging due to the lack of studies based on existing treatment guidelines in children and lack of availability of the new drugs. We report two cases of pre-XDR-TB in children who have responded well to individualized treatment regimens. Because toxic drugs are used for long duration, close monitoring of adverse drug reactions is important.

Tuberculosis in Children Hospitalized in a Low-burden Country: Description and Risk Factors of Severe Disease

BACKGROUND

In high-income countries, few pediatric studies have described the clinical expression of tuberculosis (TB) according to age, and their results are discordant. Patients <2 years of age are usually considered to be at higher risk for severe disease than older children. Our aim was to better describe pediatric TB disease severity in a low-incidence country.

METHODS

All children (<18 years of age) admitted with TB disease to the Robert Debré University Hospital, Paris, between 1992 and 2015 were included. Patients were classified by the severity of TB disease based on the original classification of Wiseman et al. Risk factors associated with severity were analyzed.

RESULTS

We included 304 patients with a median age of 9.9 years (interquartile range 3.3-13.3) and a male to female ratio of 1.04. Overall, 280/304 (92%) were classified: 168/304 (55%) were classified as showing severe TB and 112/304 (37%) as showing non-severe TB. Central nervous system disease was more frequent among patients <2 years of age than patients 2-17 years of age (5/54; 9% vs. 5/229; 2% P = 0.024). An age of ≥10 years (P = 0.001) and being born abroad (P = 0.011) were both associated with disease severity in univariate analysis. In multivariate analysis, diagnosis through symptom-based screening was independently associated with severity (odds ratio 7.1, 95% confidence interval: 3.9-12.9, P < 0.0001).

CONCLUSIONS

This description of the clinical spectrum of pediatric TB in a low-burden setting demonstrates that adolescents are the group most at risk of experiencing severe TB.

Treatment outcomes of children and adolescents receiving drug-resistant TB treatment in a routine TB programme, Mumbai, India

Background

Childhood and adolescent drug-resistant TB (DR-TB) is one of the neglected infectious diseases. Limited evidence exists around programmatic outcomes of children and adolescents receiving DR-TB treatment. The study aimed to determine the final treatment outcomes, culture conversion rates and factors associated with unsuccessful treatment outcome in children and adolescents with DR-TB.

Methods

This is a descriptive study including children (0–9 years) and adolescents (10–19 years) with DR-TB were who were initiated on ambulatory based treatment between January 2017-June 2018 in Shatabdi hospital, Mumbai, India where National TB elimination programme(NTEP) Mumbai collaborates with chest physicians and Médecins Sans Frontières(MSF) in providing comprehensive care to DR-TB patients. The patients with available end-of-treatment outcomes were included. The data was censored on February 2020.

Result

A total of 268 patients were included; 16 (6%) of them were children (0–9 years). The median(min-max) age was 17(4–19) years and 192 (72%) were females. Majority (199, 74%) had pulmonary TB. Most (58%) had MDR-TB while 42% had fluoroquinolone-resistant TB. The median(IQR) duration of treatment (n = 239) was 24(10–25) months. Median(IQR) time for culture-conversion (n = 128) was 3(3–4) months. Of 268 patients, 166(62%) had successful end-of-treatment outcomes (cured-112; completed treatment-54). Children below 10 years had higher proportion of successful treatment outcomes (94% versus 60%) compared to adolescents. Patients with undernutrition [adjusted odds-ratio, aOR (95% Confidence Interval, 95%CI): 2.5 (1.3–4.8) or those with XDR-TB [aOR (95% CI): 4.3 (1.3–13.8)] had higher likelihood of having unsuccessful DR-TB treatment outcome.

Conclusion

High proportion of successful treatment outcome was reported, better than global reports. Further, the nutritional support and routine treatment follow up should be strengthened. All oral short and long regimens including systematic use of new TB drugs (Bedaquiline and Delamanid) should be rapidly scaled up in routine TB programme, especially for the paediatric and adolescent population.

Multi-Drug Resistant and Extensively-Drug Resistant Tuberculosis

India is one of the high burden countries for tuberculosis (TB) including multi-drug resistant TB (MDR-TB) and extensively-drug resistant (XDR) TB. Drug-resistant (DR) TB has threatened the TB care and is a major health problem in many countries; treatment of DR TB has been difficult requiring use of reserve or second-line drugs, cost factors, has extensive side-effect profile and long duration of treatment. Treatment in MDR-TB are increasingly becoming individualised mainly due to preference for oral over injectable, results of drug susceptibility testing (DST), population resistance levels, history of previous TB treatment, drug tolerability and drug-to-drug interactions. Bedaquilline (BDQ) and delaminid (DLM) are new drugs available for treatment of these patients. World Health Organization (WHO) recommends use of BDQ in more than 15 y (>15 kg) patients only. Under Revised National Tuberculosis Control Programme (RNTCP) the use of this drug is recommended for patients older than 18 y only. Under RNTCP, the use of DLM is approved in children 6 y and above. Pediatric MDR/XDR TB treatment outcome with newer anti-TB drugs and regimen is lacking. Children when treated with individualized regimens have improved survival.

The Lancet Respiratory Medicine Commission: 2019 update: epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant and incurable tuberculosis

The Lancet Respiratory Medicine Commission on drug-resistant tuberculosis was published in 2017, which comprehensively reviewed and provided recommendations on various aspects of the disease. Several key new developments regarding drug-resistant tuberculosis are outlined in this Commission Update. The WHO guidelines on treating drug-resistant tuberculosis were updated in 2019 with a reclassification of second line anti-tuberculosis drugs. An injection-free MDR tuberculosis treatment regimen is now recommended. Over the past 3 years, advances in treatment include the recognition of the safety and mortality benefit of bedaquiline, the finding that the 9-11 month injectable-based 'Bangladesh' regimen was non-inferior to longer regimens, and promising interim results of a novel 6 month 3-drug regimen (bedaquiline, pretomanid, and linezolid). Studies of explanted lungs from patients with drug-resistant tuberculosis have shown substantial drug-specific gradients across pulmonary cavities, suggesting that alternative dosing and drug delivery strategies are needed to reduce functional monotherapy at the site of disease. Several controversies are discussed including the optimal route of drug administration, optimal number of drugs constituting a regimen, selection of individual drugs for a regimen, duration of the regimen, and minimal desirable standards of antibiotic stewardship. Newer rapid nucleic acid amplification test platforms, including point-of-care systems that facilitate active case-finding, are discussed. The rapid diagnosis of resistance to other drugs, (notably fluoroquinolones), and detection of resistance by targeted or whole genome sequencing will probably change the diagnostic landscape in the near future.

Tuberculosis in children: screening, diagnosis and management

PURPOSE OF REVIEW

The present review focuses on recent advances and current challenges in screening, diagnosis and management of tuberculosis (TB) in children, encompassing TB infection and TB disease, and public health priorities for screening and family engagement.

RECENT FINDINGS

Although awareness has improved in recent years that children in TB endemic areas suffer a huge disease burden, translation into better prevention and care remains challenging. Recent WHO guidelines have incorporated screening of all household contacts of pulmonary TB cases, but implementation in high incidence settings remains limited. Improved tests using noninvasive samples, such as the lateral flow urinary lipoarabinomannan assay and the new Xpert Ultra assay applied to induced sputum or stool in young children, are showing promise and further assessment is eagerly awaited. From a treatment perspective, child-friendly dispersible fixed dose combination tablets are now widely available with excellent acceptability and tolerance reported in young children.

SUMMARY

High-level government commitment to TB control as a public health priority and feasible strategies to achieve this are required to contain the global epidemic, whereas strong engagement of local TB clinics and affected families in TB prevention is essential to limit secondary cases and protect exposed children.

Use of Second-line Medications and Treatment Outcomes in Children With Tuberculosis in a Single Center From 2007 to 2018

BACKGROUND

The incidence of drug-resistant forms of tuberculosis (DR-TB) and the number of children treated with second-line drugs (SLDs) are increasing. However, limited amount of information is available regarding the use of SLDs in this population.

METHODS

To describe the treatment of pediatric TB with SLDs and factors associated with use of SLDs in children with and without documented DR-TB, records of pediatric TB patients referred to a center in Italy from 2007 to 2018 were reviewed retrospectively.

RESULTS

Of 204 children diagnosed with active TB during the study period, 42 were treated with SLDs because of confirmed or probable drug resistance (42.8%), adverse reactions to first-line drugs (7.1%), central nervous system involvement (11.9%) or unconfirmed possible drug resistance (38.1%). There were no deaths or adverse reactions to SLDs reported. Treatment was successful in 85.2% children treated with first-line drugs and 92.9% children treated with SLDs. After adjusting for calendar period, the only factor associated with DR-TB was <2 years old [odds ratio (OR): 5.24 for <2 years vs. 5-18 years; P = 0.008]. Factors associated with treatment with SLDs were TB at 2 or more sites (OR: 11.30; P < 0.001), extrapulmonary TB (OR: 8.48; P < 0.001) or adverse reactions to first-line drugs (OR: 7.48; P = 0.002). No differences were noted in age or region of origin.

CONCLUSIONS

A substantial proportion of TB children were treated with SLDs. The main reason for using SLDs was failure of a first-line drug regimen, suggesting possible DR-TB and underestimation of DR-TB in children. The use of SLD regimens was associated with a high success rate and good tolerability profile.