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Drug-Resistant Tuberculosis Treatment Outcomes among Children and Adolescents in Karachi, Pakistan. Trop Med Infect Dis 2022; 7:tropicalmed7120418. [PMID: 36548673 PMCID: PMC9788275 DOI: 10.3390/tropicalmed7120418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/25/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Significant data gaps exist for children and adolescents with drug-resistant (DR) TB, particularly from high TB incidence settings. This report provides a descriptive analysis of programmatic outcomes among children and adolescents treated for DR-TB in Pakistan. METHODS We extracted programmatic data from January 2014 to December 2019 from a tertiary care hospital with specialised child and adolescent DR-TB services. A physician assessed all children and adolescents (0-19 years) with presumptive DR-TB, including details of exposure to DR-TB, medical history, radiology, and laboratory results. All patients received treatment as per national DR-TB management guidelines based on WHO recommendations. RESULTS There were 262 treatment episodes for 247 patients enrolled during the study period. The median age of the cohort was 16 years (IQR: 13-18 years) with 16 (6.1%) children being under 5 years; 237 (90.5%) patients had pulmonary TB. The majority of the patients (194 or 74.1%) experienced a favourable treatment outcome and 26 (9.9%) died while on treatment. Female patients (78.5%) were more likely to experience favourable outcomes compared to males (64.7%; chi-sqr p-value = 0.02). CONCLUSIONS We found high rates of favourable outcomes in children and adolescents treated for DR-TB. However, there were few young children in our cohort and there was a considerable gender gap that enhanced efforts to diagnose DR-TB in young children and to elucidate and mitigate the reasons for poor outcomes amongst males.
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Zar HJ, Moore DP, Andronikou S, Argent AC, Avenant T, Cohen C, Green RJ, Itzikowitz G, Jeena P, Masekela R, Nicol MP, Pillay A, Reubenson G, Madhi SA. Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines. Afr J Thorac Crit Care Med 2020; 26:10.7196/AJTCCM.2020.v26i3.104. [PMID: 34471872 PMCID: PMC7433705 DOI: 10.7196/ajtccm.2020.v26i3.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis. OBJECTIVES To produce revised guidelines for pneumonia in South African children under 5 years of age. METHODS The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system. Sections were synthesized into an overall guideline which underwent peer review and revision. RECOMMENDATIONS Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided. VALIDATION The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.
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Affiliation(s)
- H J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
- South African Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, South Africa
| | - D P Moore
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - S Andronikou
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
- Department of Pediatric Radiology, Perelman School of Medicine, University of Philadephia, USA
| | - A C Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
| | - T Avenant
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, South Africa
| | - C Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - R J Green
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, South Africa
| | - G Itzikowitz
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
| | - P Jeena
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - R Masekela
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - M P Nicol
- Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, South Africa; and Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - A Pillay
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - G Reubenson
- Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - S A Madhi
- South African Medical Research Council Vaccine and Infectious Diseases Analytics Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: South African Research Chair in Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Seddon JA, Johnson S, Palmer M, van der Zalm MM, Lopez-Varela E, Hughes J, Schaaf HS. Multidrug-resistant tuberculosis in children and adolescents: current strategies for prevention and treatment. Expert Rev Respir Med 2020; 15:221-237. [PMID: 32965141 DOI: 10.1080/17476348.2021.1828069] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION An estimated 30,000 children develop multidrug-resistant (MDR) tuberculosis (TB) each year, with only a small proportion diagnosed and treated. This field has historically been neglected due to the perception that children with MDR-TB are challenging to diagnose and treat. Diagnostic and therapeutic developments in adults have improved pediatric management, yet further pediatric-specific research and wider implementation of evidence-based practices are required. AREAS COVERED This review combines the most recent data with expert opinion to highlight best practice in the evaluation, diagnosis, treatment, and support of children and adolescents with MDR-TB disease. A literature search of PubMed was carried out on topics related to MDR-TB in children. This review provides practical advice on MDR-TB prevention and gives updates on new regimens and novel treatments. The review also addresses host-directed therapy, comorbid conditions, special populations, psychosocial support, and post-TB morbidity, as well as identifying outstanding research questions. EXPERT OPINION Increased availability of molecular diagnostics has the potential to aid with the diagnosis of MDR-TB in children. Shorter MDR-TB disease treatment regimens have made therapy safer and shorter and further developments with novel agents and repurposed drugs should lead to additional improvements. The evidence base for MDR-TB preventive therapy is increasing.
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Affiliation(s)
- James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University , Stellenbosch, South Africa.,Section of Paediatric Infectious Diseases, Department of Infectious Diseases, Imperial College London , London, UK
| | - Sarah Johnson
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University , Stellenbosch, South Africa.,Section of Paediatric Infectious Diseases, Department of Infectious Diseases, Imperial College London , London, UK
| | - Megan Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University , Stellenbosch, South Africa
| | - Marieke M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University , Stellenbosch, South Africa
| | - Elisa Lopez-Varela
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University , Stellenbosch, South Africa.,ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat De Barcelona , Barcelona, Spain
| | - Jennifer Hughes
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University , Stellenbosch, South Africa
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University , Stellenbosch, South Africa
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Chiang SS, Dolynska M, Rybak NR, Cruz AT, Aibana O, Sheremeta Y, Petrenko V, Mamotenko A, Terleieva I, Horsburgh CR, Jenkins HE. Clinical manifestations and epidemiology of adolescent tuberculosis in Ukraine. ERJ Open Res 2020; 6:00308-2020. [PMID: 32964003 PMCID: PMC7487357 DOI: 10.1183/23120541.00308-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 11/18/2022] Open
Abstract
Background During adolescence, childhood and adult forms of tuberculosis (TB) overlap, resulting in diverse disease manifestations. Knowing which patient characteristics are associated with which manifestations may facilitate diagnosis and enhance understanding of TB pathophysiology. Methods In this cross-sectional study, we included 10–19-year-olds in Ukraine's national TB registry who started TB treatment between 2015 and 2018. Using multivariable regression, we estimated associations between patient characteristics and four presentations of TB: pleural, extrathoracic, cavitary and rifampicin-resistant (RR). We also described the epidemiology of adolescent TB in Ukraine. Results Among 2491 adolescent TB cases, 88.4% were microbiologically confirmed. RR-TB was confirmed in 16.9% of new and 29.7% of recurrent cases. Of 88 HIV-infected adolescents, 59.1% were not on antiretroviral therapy at TB diagnosis. Among 10–14-year-olds, boys had more pleural disease (adjusted OR (aOR) 2.12, 95% CI: 1.08–4.37). Extrathoracic TB was associated with age 15–19 years (aOR 0.26, 95% CI: 0.18–0.37) and HIV (aOR 3.25, 95% CI: 1.55–6.61 in 10–14-year-olds; aOR 8.18, 95% CI: 3.58–17.31 in 15–19-year-olds). Cavitary TB was more common in migrants (aOR 3.53, 95% CI: 1.66–7.61) and 15–19-year-olds (aOR 4.10, 95% CI: 3.00–5.73); among 15–19-year-olds, it was inversely associated with HIV (aOR 0.32, 95% CI: 0.13–0.70). RR-TB was associated with recurrent disease (aOR 1.87, 95% CI: 1.08–3.13), urban residence (aOR 1.27, 95% CI: 1.01–1.62) and cavitation (aOR 2.98, 95% CI: 2.35–3.78). Conclusions Age, sex, HIV and social factors impact the presentation of adolescent TB. Preventive, diagnostic and treatment activities should take these factors into consideration. Analysing 2491 cases of adolescent tuberculosis in Ukraine, associations were observed between four clinical presentations – cavitary, pleural, extrathoracic and rifampicin-resistant TB – and age, sex, HIV status, prior treatment and social factors.https://bit.ly/2XplZFt
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Affiliation(s)
- Silvia S Chiang
- Dept of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA.,Center for International Health Research, Rhode Island Hospital, Providence, RI, USA
| | - Maria Dolynska
- Dept of Tuberculosis and Pulmonology, Bogomolets National Medical University, Kyiv, Ukraine
| | - Natasha R Rybak
- Dept of Medicine, Alpert Medical School of Brown University, Providence, RI, USA.,Dept of Medicine, The Miriam Hospital, Providence, RI, USA
| | - Andrea T Cruz
- Dept of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Omowunmi Aibana
- Dept of Medicine, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Yana Sheremeta
- All-Ukrainian Network of People Living with HIV/AIDS, Kyiv, Ukraine
| | - Vasyl Petrenko
- Dept of Tuberculosis and Pulmonology, Bogomolets National Medical University, Kyiv, Ukraine
| | | | - Iana Terleieva
- Public Health Center of the Ministry of Health, Kyiv, Ukraine
| | - C Robert Horsburgh
- Dept of Medicine, Boston University School of Medicine, Boston, MA, USA.,Dept of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Helen E Jenkins
- Dept of Biostatistics, Boston University School of Public Health, Boston, MA, USA
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Tola HH, Khadoura KJ, Jimma W, Nedjat S, Majdzadeh R. Multidrug resistant tuberculosis treatment outcome in children in developing and developed countries: A systematic review and meta-analysis. Int J Infect Dis 2020; 96:12-18. [PMID: 32289559 DOI: 10.1016/j.ijid.2020.03.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/16/2020] [Accepted: 03/25/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND We aimed to compare and contrast the proportions of treatment outcome between developing and developed countries in children treated for multidrug resistance tuberculosis (MDR-TB). METHODS We conducted a systematic review and meta-analysis of articles published on children treated for MDR-TB. We searched published articles from electronic databases: PubMed/Medline, EMBASE, Scopus and Web of Science for English articles without restricting publication year. We employed random-effects meta-analysis model to estimate the pooled proportions of treatment success, death, treatment failure and lost to follow up. RESULTS We pooled data of 1,343 children obtained from 17 included studies, and the overall pooled treatment success was 77.0% (95% Confidence Interval (CI), 69.0-85.0). Pooled treatment success in developing countries was 73.0% (63.0-83.0), while in developed countries 87.0% (81.0-94.0). The overall pooled treatment failure was 3.0% (1.0-6.0), while death 8.0% (4.0-11.0) and lost to follow up 10.0% (6.0-4). CONCLUSION MDR-TB treatment success in children is well achieved in both developed and developing countries by currently available drugs. Improving MDR-TB treatment programme is vital to achieve the maximum treatment successful. Promoting research on pediatric MDR-TB treatment outcome could also help to fill evidence gap.
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Affiliation(s)
- Habteyes Hailu Tola
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University Medical, Tehran, Iran; Tuberculosis/HIV Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia.
| | - Khalid Jamal Khadoura
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University Medical, Tehran, Iran; Departiment of Internal Medicine, Shifa Complex Hospital, Gaza, Palestine.
| | - Worku Jimma
- Department of Information Science, College of Natural Sciences, Jimma University, Jimma, Ethiopia.
| | - Saharnaz Nedjat
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University Medical, Tehran, Iran; Knowledge Utilization Research Center, Tehran University Medical Sciences, Tehran, Iran.
| | - Reza Majdzadeh
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University Medical, Tehran, Iran; Knowledge Utilization Research Center, Tehran University Medical Sciences, Tehran, Iran.
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Moore BK, Erasmus L, Ershova J, Smith SE, Ndjeka N, Podewils LJ. Pre-treatment loss to follow-up among children with multidrug-resistant tuberculosis in South Africa, 2008-2010. PLoS One 2020; 15:e0230504. [PMID: 32255811 PMCID: PMC7138297 DOI: 10.1371/journal.pone.0230504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 03/03/2020] [Indexed: 11/27/2022] Open
Abstract
Multidrug-resistant (MDR) TB is more difficult to diagnose and treat compared with drug-susceptible TB. Young children are at greater risk of severe TB disease and death when treatment is delayed compared to adults. We sought to describe characteristics of children (<13 years) diagnosed with MDR TB between 2008-2010 in three South African provinces and assess factors associated with pre-treatment loss to follow-up. We matched laboratory and medical records at treatment facilities to identify pre-treatment loss and examined demographic and clinical characteristics for association with loss. Categorical variables were examined for association using Pearson's x2 or Fisher's exact test, employing Bonferroni correction for multiple pairwise comparisons. Between 2008-2010, 156 children were diagnosed with laboratory-confirmed MDR TB. Only 44% (n = 69) were documented as having received treatment. Young children (<2 years) (47/59, 80%), children with extrapulmonary (EP) TB (27/34, 79%), and children diagnosed at general hospitals (60/97, 62%) were most likely to be lost before treatment. Children most vulnerable to death from TB are most likely to be lost before treatment, possibly leading to underestimates of disease burden, case notifications, and poor outcomes among this population. Point-of-care diagnosis and robust follow-up may reduce pre-treatment loss in this population.
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Affiliation(s)
- Brittany K. Moore
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia United States of America
| | - Linda Erasmus
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Julia Ershova
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia United States of America
| | - Sarah E. Smith
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia United States of America
| | - Norbert Ndjeka
- South Africa National Department of Health, Pretoria, South Africa
| | - Laura J. Podewils
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia United States of America
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7
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Tola HH, Holakouie-Naieni K, Mansournia MA, Yaseri M, Tesfaye E, Mahamed Z, Molla Sisay M. Low enrollment and high treatment success in children with drug-resistant tuberculosis in Ethiopia: A ten years national retrospective cohort study. PLoS One 2020; 15:e0229284. [PMID: 32101580 PMCID: PMC7043800 DOI: 10.1371/journal.pone.0229284] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 02/03/2020] [Indexed: 12/24/2022] Open
Abstract
Background Limited evidence exists on the treatment outcome and factors that are associated with the duration from the initiation of treatment to death or treatment failure in children with drug resistant tuberculosis (DR-TB). Thus, we aimed to determine the proportion of treatment enrollment, status of treatment outcome and determine factors that are associated with the duration from treatment initiation to death or treatment failure in children treated for DR-TB in Ethiopia. Methods We conducted a retrospective cohort study in children younger than 15 years old who were treated for DR-TB from February 2009 to February 2019 in Ethiopia. We collected data on socio-demographic and clinical characteristics from clinical charts, registration books and laboratory result reports on 155 children. Proportion of enrollment to the treatment was calculated by dividing the total number of children who were receiving the treatment by the total number of DR-TB patients treated during the specified years. We used Cox proportional hazard models to determine factors that were associated with the duration from the beginning of the treatment to death or treatment failure. Data was analyzed using STATA version 14. Results Of the 3,478 DR-TB patients enrolled into the treatment and fulfilling our inclusion criteria during the past ten years, 155 (4.5%) were children. Of the 155 children, 75 (48.4%) completed the treatment and 51 (32.9%) were cured. Furthermore, 18 (11.6%) children were died, seven (4.5%) lost to follow up and treatment of four (2.6%) children was failed. The overall treatment success was 126 (81.3%). Age younger than 5 years old [Adjusted Hazard Ratio (AHR) = 3.2, 95%CI (1.2–8.3)], HIV sero-reactivity [AHR = 5.3, 95%CI (1.8–14.9)] and being anemic [AHR = 4.3, 95%CI (1.8–10.3)] were significantly associated with the duration from the enrollment into the treatment to death or treatment failure. Conclusion In this study, the proportion of children enrolled into DR-TB treatment was lower than the proportion of adults enrolled to the treatment (4.5% in children versus 95.5% in adults) in last ten years. Our findings also suggest that children with DR-TB can be successfully treated with standardized long term regimen. Further prospective cohort study is required to investigate factors contributing to death or treatment failure.
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Affiliation(s)
- Habteyes Hailu Tola
- Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences (TUMS), School of Public Health, Tehran, Iran
- Tuberculosis/HIV Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Kourosh Holakouie-Naieni
- Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences (TUMS), School of Public Health, Tehran, Iran
- * E-mail:
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences (TUMS), School of Public Health, Tehran, Iran
| | - Mehdi Yaseri
- Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences (TUMS), School of Public Health, Tehran, Iran
| | - Ephrem Tesfaye
- Tuberculosis/HIV Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Zemedu Mahamed
- Tuberculosis/HIV Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Million Molla Sisay
- Saint Peter’s Specialized Hospital, Research and Evidence Generation Directorate, Addis Ababa, Ethiopia
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Osman M, Harausz EP, Garcia-Prats AJ, Schaaf HS, Moore BK, Hicks RM, Achar J, Amanullah F, Barry P, Becerra M, Chiotan DI, Drobac PC, Flood J, Furin J, Gegia M, Isaakidis P, Mariandyshev A, Ozere I, Shah NS, Skrahina A, Yablokova E, Seddon JA, Hesseling AC. Treatment Outcomes in Global Systematic Review and Patient Meta-Analysis of Children with Extensively Drug-Resistant Tuberculosis. Emerg Infect Dis 2019; 25:441-450. [PMID: 30789141 PMCID: PMC6390755 DOI: 10.3201/eid2503.180852] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Extensively drug-resistant tuberculosis (XDR TB) has extremely poor treatment outcomes in adults. Limited data are available for children. We report on clinical manifestations, treatment, and outcomes for 37 children (<15 years of age) with bacteriologically confirmed XDR TB in 11 countries. These patients were managed during 1999-2013. For the 37 children, median age was 11 years, 32 (87%) had pulmonary TB, and 29 had a recorded HIV status; 7 (24%) were infected with HIV. Median treatment duration was 7.0 months for the intensive phase and 12.2 months for the continuation phase. Thirty (81%) children had favorable treatment outcomes. Four (11%) died, 1 (3%) failed treatment, and 2 (5%) did not complete treatment. We found a high proportion of favorable treatment outcomes among children, with mortality rates markedly lower than for adults. Regimens and duration of treatment varied considerably. Evaluation of new regimens in children is required.
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9
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Makiwane M, Decloedt E, Chirehwa M, Rosenkranz B, Kruger M. Adverse Drug Reactions in Paediatric In-Patients in a South African Tertiary Hospital. J Trop Pediatr 2019; 65:389-396. [PMID: 30544245 DOI: 10.1093/tropej/fmy067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The prevalence of adverse drug reaction (ADR) rates in children in sub-Saharan Africa is unknown. OBJECTIVES To describe the prevalence of ADRs in paediatric in-patients at a tertiary hospital in South Africa. METHODS This is a prospective study during a 3-month study period. Data collected included age, sex, diagnosis, medicines received and ADRs experienced. Causality were assessed, using the 10-question Naranjo probability scale and classified according to the Hartwig severity scale. RESULTS There were 61 ADRs in 18.4% (52 of 282) of patients. Median age of patients was 1.4 years (interquartile range: 0.5-5.3 years). ADR was the primary admission reason in 31%. The majority of the ADRs were moderate 45.9% (28 of 61), and only 11.5% severe (7 of 61). Paediatric oncology patients suffered significantly more ADRs (56.5%; 13 of 23) [odds ratio 7.3 (3.0-17.9), p < 0.01], followed by HIV-infected patients (42.9%; 9 of 21). CONCLUSION The prevalence of ADRs was 18.4%, while 31% was the reason for admission.
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Affiliation(s)
- Memela Makiwane
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Maxwell Chirehwa
- Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town, South Africa
| | - Bernd Rosenkranz
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Mariana Kruger
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
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10
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Harausz EP, Garcia-Prats AJ, Law S, Schaaf HS, Kredo T, Seddon JA, Menzies D, Turkova A, Achar J, Amanullah F, Barry P, Becerra M, Chan ED, Chan PC, Ioana Chiotan D, Crossa A, Drobac PC, Fairlie L, Falzon D, Flood J, Gegia M, Hicks RM, Isaakidis P, Kadri SM, Kampmann B, Madhi SA, Marais E, Mariandyshev A, Méndez-Echevarría A, Moore BK, Nargiza P, Ozere I, Padayatchi N, Ur-Rehman S, Rybak N, Santiago-Garcia B, Shah NS, Sharma S, Shim TS, Skrahina A, Soriano-Arandes A, van den Boom M, van der Werf MJ, van der Werf TS, Williams B, Yablokova E, Yim JJ, Furin J, Hesseling AC. Treatment and outcomes in children with multidrug-resistant tuberculosis: A systematic review and individual patient data meta-analysis. PLoS Med 2018; 15:e1002591. [PMID: 29995958 PMCID: PMC6040687 DOI: 10.1371/journal.pmed.1002591] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 05/18/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND An estimated 32,000 children develop multidrug-resistant tuberculosis (MDR-TB; Mycobacterium tuberculosis resistant to isoniazid and rifampin) each year. Little is known about the optimal treatment for these children. METHODS AND FINDINGS To inform the pediatric aspects of the revised World Health Organization (WHO) MDR-TB treatment guidelines, we performed a systematic review and individual patient data (IPD) meta-analysis, describing treatment outcomes in children treated for MDR-TB. To identify eligible reports we searched PubMed, LILACS, Embase, The Cochrane Library, PsychINFO, and BioMedCentral databases through 1 October 2014. To identify unpublished data, we reviewed conference abstracts, contacted experts in the field, and requested data through other routes, including at national and international conferences and through organizations working in pediatric MDR-TB. A cohort was eligible for inclusion if it included a minimum of three children (aged <15 years) who were treated for bacteriologically confirmed or clinically diagnosed MDR-TB, and if treatment outcomes were reported. The search yielded 2,772 reports; after review, 33 studies were eligible for inclusion, with IPD provided for 28 of these. All data were from published or unpublished observational cohorts. We analyzed demographic, clinical, and treatment factors as predictors of treatment outcome. In order to obtain adjusted estimates, we used a random-effects multivariable logistic regression (random intercept and random slope, unless specified otherwise) adjusted for the following covariates: age, sex, HIV infection, malnutrition, severe extrapulmonary disease, or the presence of severe disease on chest radiograph. We analyzed data from 975 children from 18 countries; 731 (75%) had bacteriologically confirmed and 244 (25%) had clinically diagnosed MDR-TB. The median age was 7.1 years. Of 910 (93%) children with documented HIV status, 359 (39%) were infected with HIV. When compared to clinically diagnosed patients, children with confirmed MDR-TB were more likely to be older, to be infected with HIV, to be malnourished, and to have severe tuberculosis (TB) on chest radiograph (p < 0.001 for all characteristics). Overall, 764 of 975 (78%) had a successful treatment outcome at the conclusion of therapy: 548/731 (75%) of confirmed and 216/244 (89%) of clinically diagnosed children (absolute difference 14%, 95% confidence interval [CI] 8%-19%, p < 0.001). Treatment was successful in only 56% of children with bacteriologically confirmed TB who were infected with HIV who did not receive any antiretroviral treatment (ART) during MDR-TB therapy, compared to 82% in children infected with HIV who received ART during MDR-TB therapy (absolute difference 26%, 95% CI 5%-48%, p = 0.006). In children with confirmed MDR-TB, the use of second-line injectable agents and high-dose isoniazid (15-20 mg/kg/day) were associated with treatment success (adjusted odds ratio [aOR] 2.9, 95% CI 1.0-8.3, p = 0.041 and aOR 5.9, 95% CI 1.7-20.5, p = 0.007, respectively). These findings for high-dose isoniazid may have been affected by site effect, as the majority of patients came from Cape Town. Limitations of this study include the difficulty of estimating the treatment effects of individual drugs within multidrug regimens, only observational cohort studies were available for inclusion, and treatment decisions were based on the clinician's perception of illness, with resulting potential for bias. CONCLUSIONS This study suggests that children respond favorably to MDR-TB treatment. The low success rate in children infected with HIV who did not receive ART during their MDR-TB treatment highlights the need for ART in these children. Our findings of individual drug effects on treatment outcome should be further evaluated.
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Affiliation(s)
- Elizabeth P Harausz
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.,Military HIV Research Program, Bethesda, Maryland, United States of America
| | - Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Stephanie Law
- Montreal Chest Institute, McGill University, Montreal, Quebec, Canada
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - James A Seddon
- Centre for International Child Health, Imperial College, London, United Kingdom
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, Quebec, Canada
| | - Anna Turkova
- Imperial College Healthcare NHS Trust, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Jay Achar
- Manson Unit, Médecins Sans Frontières (MSF), London, United Kingdom
| | | | - Pennan Barry
- California Department of Public Health, Sacramento, California, United States of America
| | - Mercedes Becerra
- Partners In Health, Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Edward D Chan
- Denver Veterans Affairs Medical Center, National Jewish Health, Denver, Colorado, United States of America
| | - Pei Chun Chan
- Division of Chronic Infectious Disease, Centers for Disease Control, Taipei, Taiwan
| | - Domnica Ioana Chiotan
- Epidemiological Surveillance Department, Romanian National TB Program, Bucharest, Romania
| | - Aldo Crossa
- New York City Department of Health and Mental Hygiene, New York, New York, United States of America
| | - Peter C Drobac
- Partners In Health, Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Lee Fairlie
- Wits Reproductive Health & HIV Institute (WRHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Dennis Falzon
- Laboratories, Diagnostics and Drug Resistance Unit, Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Jennifer Flood
- California Department of Public Health, Sacramento, California, United States of America
| | - Medea Gegia
- Technical Support Coordination, Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Robert M Hicks
- Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Petros Isaakidis
- Médecins Sans Frontières (MSF)/Doctors Without Borders, Mumbai, India
| | - S M Kadri
- Disease Control, Directorate of Health Services, Kashmir, India
| | - Beate Kampmann
- Paediatric Infection & Immunity, Centre of International Child Health, Imperial College London, London, United Kingdom.,Vaccines & Immunity Theme, MRC Unit The Gambia, Banjul, The Gambia
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, and Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Else Marais
- Department of Clinical Microbiology and Infectious Diseases, University of the Witwatersrand and the National Health Laboratory Services, Johannesburg, South Africa
| | | | - Ana Méndez-Echevarría
- Pediatric, Infectious and Tropical Diseases Department, Hospital La Paz, Madrid, Spain
| | - Brittany Kathryn Moore
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Parpieva Nargiza
- Republican Scientific Medical Center of Phtiziology and Pulmonology, Ministry of Health, Tashkent, Uzbekistan
| | - Iveta Ozere
- Riga Eastern Clinical University Hospital, Centre for Tuberculosis and Lung Diseases, Riga, Latvia
| | | | | | - Natasha Rybak
- Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Begoña Santiago-Garcia
- Pediatric Infectious Diseases Unit, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - N Sarita Shah
- Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Sangeeta Sharma
- Department of Pediatrics, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Tae Sun Shim
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Alena Skrahina
- The Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - Antoni Soriano-Arandes
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Unit of International Health-Tuberculosis Drassanes-Vall Hebron, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Martin van den Boom
- Joint Tuberculosis, HIV & Viral Hepatitis Programme, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Marieke J van der Werf
- Disease Programme Tuberculosis, European Centre for Disease Prevention and Control, Stockholm, Sweden
| | | | - Bhanu Williams
- Northwick Park Hospital, London Northwest Healthcare NHS Trust, London, United Kingdom
| | - Elena Yablokova
- Northern State Medical University, Arkhangelsk, Russian Federation
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Tao NN, He XC, Zhang XX, Liu Y, Yu CB, Li HC. Drug-Resistant Tuberculosis among Children, China, 2006-2015. Emerg Infect Dis 2018; 23:1800-1805. [PMID: 29047424 PMCID: PMC5652408 DOI: 10.3201/eid2311.170234] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Microbial drug resistance has become a major public health concern worldwide. To acquire epidemiologic data on drug-resistant tuberculosis (DR TB) among children, a major cause of illness and death for this population, we conducted a retrospective study of 2006–2015 data from 36 TB prevention and control institutions in Shandong Province, China. A total of 14,223 new TB cases, among which children (<18 years of age) accounted for only 5.5%, were caused by culture-confirmed Mycobacterium tuberculosis. Among children with TB, 18.9% had DR TB and 6.9% had multidrug-resistant TB. Over the past decade, the percentage of DR TB; multidrug-resistant TB; and overall first-line drug resistance for isoniazid, rifampin, ethambutol, and streptomycin among children increased significantly (at least 12%). Understanding the long-term trends of DR TB among children can shed light on the performance of TB control programs, thereby contributing to global TB control.
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12
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Treatment Outcomes of Children With HIV Infection and Drug-resistant TB in Three Provinces in South Africa, 2005-2008. Pediatr Infect Dis J 2017; 36:e322-e327. [PMID: 28746263 PMCID: PMC5797992 DOI: 10.1097/inf.0000000000001691] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe outcomes of HIV-infected pediatric patients with drug-resistant tuberculosis (DR TB). METHODS Demographic, clinical and laboratory data from charts of pediatric patients treated for DR TB during 2005-2008 were collected retrospectively from 5 multi-DR TB hospitals in South Africa. Data were summarized, and Pearson χ test or Fisher exact test was used to assess differences in variables of interest by HIV status. A time-to-event analysis was conducted using days from start of treatment to death. Variables of interest were first assessed using the Kaplan-Meier method. Cox proportional hazard models were fit to estimate crude and adjusted hazard ratios. RESULTS Of 423 eligible participants, 398 (95%) had culture-confirmed DR TB and 238 (56%) were HIV infected. A total of 54% were underweight, 42% were male and median age was 10.7 years (interquartile range: 5.5-15.3). Of the 423 participants, 245 (58%) were successfully treated, 69 (16%) died, treatment failed in 3 (1%), 36 (9%) were lost to follow-up and 70 (17%) were still on treatment, transferred or had unknown outcomes. Time to death differed by HIV status (P = 0.008), sex (P < 0.001), year of tuberculosis diagnosis (P = 0.05) and weight status (P = 0.002). Over the 2-year risk period, the adjusted rate of death was 2-fold higher among participants with HIV compared with HIV-negative participants (adjusted hazard ratio = 2.28; 95% confidence interval: 1.11-4.68). CONCLUSIONS Male, underweight and HIV-infected children with DR TB were more likely to experience death when compared with other children with DR TB within this study population.
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Abstract
PURPOSE OF REVIEW It is 20 years since the start of the combination antiretroviral therapy (cART) era and more than 10 years since cART scale-up began in resource-limited settings. We examined survival of vertically HIV-infected infants and children in the cART era. RECENT FINDINGS Good survival has been achieved on cART in all settings with up to 10-fold mortality reductions compared with before cART availability. Although mortality risk remains high in the first few months after cART initiation in young children with severe disease, it drops rapidly thereafter even for those who started with advanced disease, and longer term mortality risk is low. However, suboptimal retention on cART in routine programs threatens good survival outcomes and even on treatment children continue to experience high comorbidity risk; infections remain the major cause of death. Interventions to address infection risk include a cotrimoxazole prophylaxis, isoniazid preventive therapy, routine childhood and influenza immunization, and improving maternal survival. SUMMARY Pediatric survival has improved substantially with cART and HIV-infected children are aging into adulthood. It is important to ensure access to diagnosis and early cART, good program retention as well as optimal comorbidity prophylaxis and treatment to achieve the best possible long-term survival and health outcomes for vertically infected children.
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Tierney DB, Milstein MB, Manjourides J, Furin JJ, Mitnick CD. Treatment Outcomes for Adolescents With Multidrug-Resistant Tuberculosis in Lima, Peru. Glob Pediatr Health 2016; 3:2333794X16674382. [PMID: 27826599 PMCID: PMC5084611 DOI: 10.1177/2333794x16674382] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/05/2016] [Accepted: 10/07/2016] [Indexed: 11/21/2022] Open
Abstract
Treatment outcomes for adolescents with multidrug-resistant tuberculosis are rarely reported and, to date, have been poor. Among 90 adolescents from Lima, Peru, 68 (75.6%) achieved cure or completion of treatment. Unsuccessful treatment was less common in the Peru cohort than previously described in the literature.
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Affiliation(s)
| | - Meredith B Milstein
- Harvard Medical School, Boston, MA, USA; Northeastern University, Boston, MA, USA
| | | | | | - Carole D Mitnick
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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15
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Dodd PJ, Sismanidis C, Seddon JA. Global burden of drug-resistant tuberculosis in children: a mathematical modelling study. THE LANCET. INFECTIOUS DISEASES 2016; 16:1193-1201. [DOI: 10.1016/s1473-3099(16)30132-3] [Citation(s) in RCA: 136] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/13/2016] [Accepted: 05/17/2016] [Indexed: 11/26/2022]
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16
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Chiang SS, Starke JR, Miller AC, Cruz AT, Del Castillo H, Valdivia WJ, Tunque G, García F, Contreras C, Lecca L, Alarcón VA, Becerra MC. Baseline Predictors of Treatment Outcomes in Children With Multidrug-Resistant Tuberculosis: A Retrospective Cohort Study. Clin Infect Dis 2016; 63:1063-71. [PMID: 27458026 DOI: 10.1093/cid/ciw489] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/06/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Globally, >30 000 children fall sick with multidrug-resistant (MDR) tuberculosis every year. Without robust pediatric data, clinical management follows international guidelines that are based on studies in adults and expert opinion. We aimed to identify baseline predictors of death, treatment failure, and loss to follow-up among children with MDR tuberculosis disease treated with regimens tailored to their drug susceptibility test (DST) result or to the DST result of a source case. METHODS This retrospective cohort study included all children ≤15 years old with confirmed and probable MDR tuberculosis disease who began tailored regimens in Lima, Peru, between 2005 and 2009. Using logistic regression, we examined associations between baseline patient and treatment characteristics and (1) death or treatment failure and (2) loss to follow-up. RESULTS Two hundred eleven of 232 (90.9%) children had known treatment outcomes, of whom 163 (77.2%) achieved cure or probable cure, 29 (13.7%) were lost to follow-up, 10 (4.7%) experienced treatment failure, and 9 (4.3%) died. Independent baseline predictors of death or treatment failure were the presence of severe disease (adjusted odds ratio [aOR], 4.96; 95% confidence interval [CI], 1.61-15.26) and z score ≤-1 (aOR, 3.39; 95% CI, 1.20-9.54). We did not identify any independent predictors of loss to follow-up. CONCLUSIONS High cure rates can be achieved in children with MDR tuberculosis using tailored regimens containing second-line drugs. However, children faced significantly higher risk of death or treatment failure if they had severe disease or were underweight. These findings highlight the need for early interventions that can improve treatment outcomes for children with MDR tuberculosis.
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Affiliation(s)
- Silvia S Chiang
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey R Starke
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Ann C Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Andrea T Cruz
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | | | | | - Fanny García
- Partners In Health (Socios En Salud Sucursal Peru)
| | | | - Leonid Lecca
- Partners In Health (Socios En Salud Sucursal Peru)
| | - Valentina A Alarcón
- Estrategia Sanitaria Nacional de Prevención y Control de la Tuberculosis, Ministerio de Salud, Lima, Peru
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts Partners In Health (Socios En Salud Sucursal Peru)
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