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Vogel M, Utpatel C, Corbett C, Kohl TA, Iskakova A, Ahmedov S, Antonenka U, Dreyer V, Ibrahimova A, Kamarli C, Kosimova D, Mohr V, Sahalchyk E, Sydykova M, Umetalieva N, Kadyrov A, Kalmambetova G, Niemann S, Hoffmann H. Implementation of whole genome sequencing for tuberculosis diagnostics in a low-middle income, high MDR-TB burden country. Sci Rep 2021; 11:15333. [PMID: 34321545 PMCID: PMC8319420 DOI: 10.1038/s41598-021-94297-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/06/2021] [Indexed: 11/09/2022] Open
Abstract
Whole genome sequencing (WGS) is revolutionary for diagnostics of TB and its mutations associated with drug-resistances, but its uptake in low- and middle-income countries is hindered by concerns of implementation feasibility. Here, we provide a proof of concept for its successful implementation in such a setting. WGS was implemented in the Kyrgyz Republic. We estimated needs of up to 55 TB-WGS per week and chose the MiSeq platform (Illumina, USA) because of its capacity of up to 60 TB-WGS per week. The project's timeline was completed in 93-weeks. Costs of large equipment and accompanying costs were 222,065 USD and 8462 USD, respectively. The first 174 WGS costed 277 USD per sequence, but this was skewed by training inefficiencies. Based on real prices and presuming optimal utilization of WGS capacities, WGS costs could drop to 167 and 141 USD per WGS using MiSeq Reagent Kits v2 (500-cycles) and v3 (600-cycles), respectively. Five trainings were required to prepare the staff for autonomous WGS which cost 48,250 USD. External assessment confirmed excellent performance of WGS by the Kyrgyz laboratory in an interlaboratory comparison of 30 M. tuberculosis genomes showing complete agreeance of results.
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Affiliation(s)
- Monica Vogel
- Institute of Microbiology and Laboratory Medicine, Department IML Red GmbH, WHO - Supranational Tuberculosis Reference Laboratory Munich-Gauting, Robert Koch-Allee 2, 82131, Gauting, Germany
| | - Christian Utpatel
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | - Caroline Corbett
- Institute of Microbiology and Laboratory Medicine, Department IML Red GmbH, WHO - Supranational Tuberculosis Reference Laboratory Munich-Gauting, Robert Koch-Allee 2, 82131, Gauting, Germany
| | - Thomas A Kohl
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | - Altyn Iskakova
- Republican Tuberculosis Reference Laboratory, Bishkek, Kyrgyz Republic
| | - Sevim Ahmedov
- USAID, Bureau for Global Health, TB Division, Washington, DC, USA
| | - Uladzimir Antonenka
- Institute of Microbiology and Laboratory Medicine, Department IML Red GmbH, WHO - Supranational Tuberculosis Reference Laboratory Munich-Gauting, Robert Koch-Allee 2, 82131, Gauting, Germany
| | - Viola Dreyer
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | - Ainura Ibrahimova
- ABT Associates, Defeat TB Project Management, Bishkek, Kyrgyz Republic
| | | | - Dilorom Kosimova
- ABT Associates, Defeat TB Project Management, Bishkek, Kyrgyz Republic
| | - Vanessa Mohr
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | - Evgeni Sahalchyk
- Institute of Microbiology and Laboratory Medicine, Department IML Red GmbH, WHO - Supranational Tuberculosis Reference Laboratory Munich-Gauting, Robert Koch-Allee 2, 82131, Gauting, Germany
| | - Meerim Sydykova
- Republican Tuberculosis Reference Laboratory, Bishkek, Kyrgyz Republic
| | - Nagira Umetalieva
- Institute of Microbiology and Laboratory Medicine, Department IML Red GmbH, WHO - Supranational Tuberculosis Reference Laboratory Munich-Gauting, Robert Koch-Allee 2, 82131, Gauting, Germany
| | - Abdylat Kadyrov
- Republican Tuberculosis Center, National Tuberculosis Project Management, Bishkek, Kyrgyz Republic
| | | | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | - Harald Hoffmann
- Institute of Microbiology and Laboratory Medicine, Department IML Red GmbH, WHO - Supranational Tuberculosis Reference Laboratory Munich-Gauting, Robert Koch-Allee 2, 82131, Gauting, Germany.
- SYNLAB Gauting, SYNLAB Human Genetics, Munich-Gauting, Germany.
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Time to Multidrug-Resistant Tuberculosis Treatment Initiation in Association with Treatment Outcomes in Shanghai, China. Antimicrob Agents Chemother 2018; 62:AAC.02259-17. [PMID: 29437632 DOI: 10.1128/aac.02259-17] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 01/29/2018] [Indexed: 11/20/2022] Open
Abstract
In high tuberculosis (TB)-burden countries such as China, the diagnosis of multidrug-resistant tuberculosis (MDR-TB) using conventional drug susceptibility testing (DST) takes months, making treatment delay inevitable. Poor outcomes of MDR-TB might be associated with delayed, even inappropriate, treatment. The purposes of this study were to investigate the time to MDR-TB treatment initiation and to assess the association between early treatment and treatment outcomes. Between April 2011 and December 2014, this population-based retrospective cohort study collected the demographic and clinical characteristics and the drug susceptibility profiles of all registered MDR-TB patients in Shanghai, China. The dates of TB and MDR-TB diagnoses, DST performance, and treatment initiation were extracted to calculate the times to treatment. In total, 284 of 346 MDR-TB patients were eligible for analysis, and 68.3% (194/284) had favored outcomes. The median time to treatment initiation from TB diagnosis was 172 days among those with favored outcomes and 190 days among those with poor outcomes. Treatments initiated within 60 days after performing DST (odds ratio [OR], 2.56; 95% confidence interval [CI], 1.22 to 5.36) and empirical treatments (OR, 2.09; 95% CI, 1.01 to 4.32) were positively associated with favored outcomes. Substantial delays to MDR-TB treatment were observed when conventional DST was used. Early treatment predicted favored outcomes. Rapid diagnostic methods should be scaled up and improvements should be made in patient management and information linkage to reduce treatment delay.
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Ramalho DMP, Miranda PFC, Andrade MK, Brígido T, Dalcolmo MP, Mesquita E, Dias CF, Gambirasio AN, Ueleres Braga J, Detjen A, Phillips PPJ, Langley I, Fujiwara PI, Squire SB, Oliveira MM, Kritski AL. Outcomes from patients with presumed drug resistant tuberculosis in five reference centers in Brazil. BMC Infect Dis 2017; 17:571. [PMID: 28810911 PMCID: PMC5558720 DOI: 10.1186/s12879-017-2669-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 08/07/2017] [Indexed: 11/10/2022] Open
Abstract
Background The implementation of rapid drug susceptibility testing (DST) is a current global priority for TB control. However, data are scarce on patient-relevant outcomes for presumptive diagnosis of drug-resistant tuberculosis (pDR-TB) evaluated under field conditions in high burden countries. Methods Observational study of pDR-TB patients referred by primary and secondary health units. TB reference centers addressing DR-TB in five cities in Brazil. Patients age 18 years and older were eligible if pDR-TB, culture positive results for Mycobacterium tuberculosis and, if no prior DST results from another laboratory were used by a physician to start anti-TB treatment. The outcome measures were median time from triage to initiating appropriate anti-TB treatment, empirical treatment and, the treatment outcomes. Results Between February,16th, 2011 and February, 15th, 2012, among 175 pDR TB cases, 110 (63.0%) confirmed TB cases with DST results were enrolled. Among study participants, 72 (65.5%) were male and 62 (56.4%) aged 26 to 45 years. At triage, empirical treatment was given to 106 (96.0%) subjects. Among those, 85 were treated with first line drugs and 21 with second line. Median time for DST results was 69.5 [interquartile - IQR: 35.7–111.0] days and, for initiating appropriate anti-TB treatment, the median time was 1.0 (IQR: 0–41.2) days. Among 95 patients that were followed-up during the first 6 month period, 24 (25.3%; IC: 17.5%–34.9%) changed or initiated the treatment after DST results: 16/29 MDRTB, 5/21 DR-TB and 3/45 DS-TB cases. Comparing the treatment outcome to DS-TB cases, MDRTB had higher proportions changing or initiating treatment after DST results (p = 0.01) and favorable outcomes (p = 0.07). Conclusions This study shows a high rate of empirical treatment and long delay for DST results. Strategies to speed up the detection and early treatment of drug resistant TB should be prioritized.
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Affiliation(s)
- D M P Ramalho
- Tuberculosis Academic Program, Medical School and Hospital Complex HUCFF-IDT, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - P F C Miranda
- Tuberculosis Academic Program, Medical School and Hospital Complex HUCFF-IDT, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - M K Andrade
- Tuberculosis Academic Program, Medical School and Hospital Complex HUCFF-IDT, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Helio Fraga Reference Center - ENSP -Fiocruz, Rio de Janeiro, Brazil
| | - T Brígido
- Messejana Hospital -State Secretary of Health, Fortaleza, Ceará, Brazil
| | - M P Dalcolmo
- Helio Fraga Reference Center - ENSP -Fiocruz, Rio de Janeiro, Brazil
| | - E Mesquita
- Ary Parreiras Institute - State Secretary of Health, Rio de Janeiro, Brazil
| | - C F Dias
- Sanatório Partenon Hospital - State Secretary of Health, Porto Alegre, Rio Grande do Sul, Brazil
| | - A N Gambirasio
- Clemente Ferreira Institute - State Secretary of Health, Sao Paulo, Brazil
| | - J Ueleres Braga
- Helio Fraga Reference Center - ENSP -Fiocruz, Rio de Janeiro, Brazil
| | - A Detjen
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | | | - I Langley
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - P I Fujiwara
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - S B Squire
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - M M Oliveira
- Tuberculosis Academic Program, Medical School and Hospital Complex HUCFF-IDT, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - A L Kritski
- Tuberculosis Academic Program, Medical School and Hospital Complex HUCFF-IDT, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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Velásquez GE, Cegielski JP, Murray MB, Yagui MJA, Asencios LL, Bayona JN, Bonilla CA, Jave HO, Yale G, Suárez CZ, Sanchez E, Rojas C, Atwood SS, Contreras CC, Santa Cruz J, Shin SS. Impact of HIV on mortality among patients treated for tuberculosis in Lima, Peru: a prospective cohort study. BMC Infect Dis 2016; 16:45. [PMID: 26831140 PMCID: PMC4736097 DOI: 10.1186/s12879-016-1375-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 01/22/2016] [Indexed: 11/17/2022] Open
Abstract
Background Human immunodeficiency virus (HIV)-associated tuberculosis deaths have decreased worldwide over the past decade. We sought to evaluate the effect of HIV status on tuberculosis mortality among patients undergoing treatment for tuberculosis in Lima, Peru, a low HIV prevalence setting. Methods We conducted a prospective cohort study of patients treated for tuberculosis between 2005 and 2008 in two adjacent health regions in Lima, Peru (Lima Ciudad and Lima Este). We constructed a multivariate Cox proportional hazards model to evaluate the effect of HIV status on mortality during tuberculosis treatment. Results Of 1701 participants treated for tuberculosis, 136 (8.0 %) died during tuberculosis treatment. HIV-positive patients constituted 11.0 % of the cohort and contributed to 34.6 % of all deaths. HIV-positive patients were significantly more likely to die (25.1 vs. 5.9 %, P < 0.001) and less likely to be cured (28.3 vs. 39.4 %, P = 0.003). On multivariate analysis, positive HIV status (hazard ratio [HR] = 6.06; 95 % confidence interval [CI], 3.96–9.27), unemployment (HR = 2.24; 95 % CI, 1.55–3.25), and sputum acid-fast bacilli smear positivity (HR = 1.91; 95 % CI, 1.10–3.31) were significantly associated with a higher hazard of death. Conclusions We demonstrate that positive HIV status was a strong predictor of mortality among patients treated for tuberculosis in the early years after Peru started providing free antiretroviral therapy. As HIV diagnosis and antiretroviral therapy provision are more widely implemented for tuberculosis patients in Peru, future operational research should document the changing profile of HIV-associated tuberculosis mortality.
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Affiliation(s)
- Gustavo E Velásquez
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA. .,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - J Peter Cegielski
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA. .,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA. .,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.
| | - Martin J A Yagui
- Oficina General de Investigación y Transferencia Tecnológica, Instituto Nacional de Salud, Lima, Perú. .,Departamento Académico de Medicina Preventiva y Salud Pública, Universidad Nacional Mayor de San Marcos, Lima, Perú.
| | - Luis L Asencios
- Laboratorio Nacional de Referencia de Micobacterias, Instituto Nacional de Salud, Lima, Perú.
| | - Jaime N Bayona
- Health, Nutrition and Population, The World Bank Group, Washington DC, USA.
| | - César A Bonilla
- Estrategia Sanitaria Nacional de Prevención y Control de la Tuberculosis, Ministerio de Salud del Perú, Lima, Perú.
| | - Hector O Jave
- Estrategia Sanitaria Nacional de Prevención y Control de la Tuberculosis, Ministerio de Salud del Perú, Lima, Perú.
| | - Gloria Yale
- Dirección de Salud V Lima Ciudad, Programa de Control de Tuberculosis, Lima, Perú.
| | - Carmen Z Suárez
- Dirección de Salud IV Lima Este, Programa de Control de Tuberculosis, Lima, Perú.
| | - Eduardo Sanchez
- Servicio de Enfermedades Infecciosas y Tropicales, Hospital Nacional Hipólito Unanue, Lima, Perú.
| | - Christian Rojas
- Servicio de Neumología, Instituto Nacional Cardiovascular "Carlos Alberto Peschiera Carrillo", Lima, Perú.
| | - Sidney S Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.
| | | | | | - Sonya S Shin
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA. .,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA. .,Partners In Health / Socios En Salud, Lima, Perú.
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Abstract
The challenge of diagnosing childhood tuberculosis (TB) results from its paucibacillary nature and the difficulties of sputum collection in children. Mycobacterial culture, the diagnostic gold standard, provides microbiological confirmation in only 30% to 40% of childhood pulmonary TB cases and takes up to 6 weeks to result. Conventional drug susceptibility testing requires an additional 2 to 4 weeks after culture confirmation. In response to the low sensitivity and long wait time of the traditional diagnostic approach, many new assays have been developed. These new tools have shortened time to result; however, none of them offer greater sensitivity than culture.
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Affiliation(s)
- Silvia S Chiang
- Section of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, 1102 Bates Street, Suite 1150, Houston, TX 77030, USA; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Douglas S Swanson
- Division of Infectious Diseases, Department of Pediatrics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Jeffrey R Starke
- Section of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, 1102 Bates Street, Suite 1150, Houston, TX 77030, USA.
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Martin A, Imperiale B, Ravolonandriana P, Coban AY, Akgunes A, Ikram A, Satti L, Odoun M, Pandey P, Mishra M, Affolabi D, Singh U, Rasolofo V, Morcillo N, Vandamme P, Palomino JC. Prospective multicentre evaluation of the direct nitrate reductase assay for the rapid detection of extensively drug-resistant tuberculosis. J Antimicrob Chemother 2013; 69:441-4. [DOI: 10.1093/jac/dkt353] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Wells WA, Boehme CC, Cobelens FG, Daniels C, Dowdy D, Gardiner E, Gheuens J, Kim P, Kimerling ME, Kreiswirth B, Lienhardt C, Mdluli K, Pai M, Perkins MD, Peter T, Zignol M, Zumla A, Schito M. Alignment of new tuberculosis drug regimens and drug susceptibility testing: a framework for action. THE LANCET. INFECTIOUS DISEASES 2013; 13:449-58. [PMID: 23531393 PMCID: PMC4012744 DOI: 10.1016/s1473-3099(13)70025-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
New tuberculosis drug regimens are creating new priorities for drug susceptibility testing (DST) and surveillance. To minimise turnaround time, rapid DST will need to be prioritised, but developers of these assays will need better data about the molecular mechanisms of resistance. Efforts are underway to link mutations with drug resistance and to develop strain collections to enable assessment of new diagnostic assays. In resource-limited settings, DST might not be appropriate for all patients with tuberculosis. Surveillance data and modelling will help country stakeholders to design appropriate DST algorithms and to decide whether to change drug regimens. Finally, development of practical DST assays is needed so that, in countries where surveillance and modelling show that DST is advisable, these assays can be used to guide clinical decisions for individual patients. If combined judiciously during both development and implementation, new tuberculosis regimens and new DST assays have enormous potential to improve patient outcomes and reduce the burden of disease.
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Affiliation(s)
| | | | - Frank G.J. Cobelens
- Department of Global Health, Academic Medical Center; and Amsterdam Institute of Global Health and Development, Amsterdam, The Netherlands
| | | | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Jan Gheuens
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Peter Kim
- National Institutes of Allergy and Infectious Disease, Bethesda, MD, USA
| | | | - Barry Kreiswirth
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA
| | | | - Khisi Mdluli
- Global Alliance for TB Drug Development, New York, NY, USA
| | - Madhukar Pai
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
| | - Mark D. Perkins
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Trevor Peter
- Clinton Health Access Initiative, Boston, MA, USA
| | - Matteo Zignol
- Stop TB Department, World Health Organization, Geneva, Switzerland
| | | | - Marco Schito
- HJF-DAIDS, a Division of The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Contractor to NIAID, NIH, DHHS, Bethesda, MD, USA
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Magee MJ, Bloss E, Shin SS, Contreras C, Huaman HA, Ticona JC, Bayona J, Bonilla C, Yagui M, Jave O, Cegielski JP. Clinical characteristics, drug resistance, and treatment outcomes among tuberculosis patients with diabetes in Peru. Int J Infect Dis 2013; 17:e404-12. [PMID: 23434400 DOI: 10.1016/j.ijid.2012.12.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 12/10/2012] [Accepted: 12/14/2012] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVES Diabetes is a risk factor for active tuberculosis (TB). Data are limited regarding the association between diabetes and TB drug resistance and treatment outcomes. We examined characteristics of TB patients with and without diabetes in a Peruvian cohort at high risk for drug-resistant TB. Among TB patients with diabetes (TB-DM), we studied the association between diabetes clinical/management characteristics and TB drug resistance and treatment outcomes. METHODS During 2005-2008, adults with suspected TB with respiratory symptoms in Lima, Peru, who received rapid drug susceptibility testing (DST), were prospectively enrolled and followed during treatment. Bivariate and Kaplan-Meier analyses were used to examine the relationships of diabetes characteristics with drug-resistant TB and TB outcomes. RESULTS Of 1671 adult TB patients enrolled, 186 (11.1%) had diabetes. TB-DM patients were significantly more likely than TB patients without diabetes to be older, have had no previous TB treatment, and to have a body mass index (BMI) >18.5 kg/m(2) (p<0.05). In patients without and with previous TB treatment, the prevalence of multidrug-resistant TB was 23% and 26%, respectively, among patients without diabetes, and 12% and 28%, respectively, among TB-DM patients. Among 149 TB-DM patients with DST results, 104 (69.8%) had drug-susceptible TB and 45 (30.2%) had drug-resistant TB, of whom 29 had multidrug-resistant TB. There was no association between diabetes characteristics and drug-resistant TB. Of 136 TB-DM patients with outcome information, 107 (78.7%) had a favorable TB outcome; active diabetes management was associated with a favorable outcome. CONCLUSIONS Diabetes was common in a cohort of TB patients at high risk for drug-resistant TB. Despite prevalent multidrug-resistant TB among TB-DM patients, the majority had a favorable TB treatment outcome.
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Affiliation(s)
- M J Magee
- Rollins School of Public Health, Emory University, Atlanta, USA
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