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Raad R, Dixon J, Gorsky M, Hoddinott G. Cycles of antibiotic use and emergent antimicrobial resistance in the South African tuberculosis programme (1950-2021): A scoping review and critical reflections on stewardship. Glob Public Health 2024; 19:2356623. [PMID: 38771831 DOI: 10.1080/17441692.2024.2356623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 05/13/2024] [Indexed: 05/23/2024]
Abstract
The emergent threat of antimicrobial resistance (AMR) has resulted in debates around the use and preservation of effective antimicrobials. Concerns around AMR reflect a history of increasing dependence on antibiotics to address disease epidemics rooted in profound structural and systemic challenges. In the context of global health, this process, often referred to as pharmaceuticalisation, has commonly occurred within disease programmes, of which lessons are vital for adding nuance to conversations around antimicrobial stewardship. Tuberculosis (TB) is a notable example. A disease which accounts for one-third of AMR globally and remains the leading cause of death from a single infectious agent in many low - and middle-income countries, including South Africa. In this scoping review, we chart TB science in South Africa over 70 years of programming. We reviewed published manuscripts about the programme and critically reflected on the implications of our findings for stewardship. We identified cycles of programmatic responses to new drug availability and the emergence of drug resistance, which intersected with cycles of pharmaceuticalisation. These cycles reflect the political, economic, and social factors influencing programmatic decision-making. Our analysis offers a starting point for research exploring these cycles and drawing out implications for stewardship across the TB and AMR communities.
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Affiliation(s)
- Rene Raad
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Justin Dixon
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The Health Research Institute Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Martin Gorsky
- Centre for History in Public Health, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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2
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Mary Prince R, Khangarot S, Haque QF, Mittal A, Somani R, Grover M. Outcomes of bedaquiline-containing regimen in the treatment of adults with drug-resistant tuberculosis in a tertiary care center in Rajasthan. Monaldi Arch Chest Dis 2023; 94. [PMID: 37551096 DOI: 10.4081/monaldi.2023.2618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/06/2023] [Indexed: 08/09/2023] Open
Abstract
The emergence of drug-resistant strains of Mycobacterium tuberculosis has become a significant public health problem and has led to a setback in the efforts to end tuberculosis (TB) worldwide. The longer duration, heavier pill load, and higher toxicity profile of drug-resistant TB regimens compared to those for drug-susceptible TB lead to reduced adherence and worse treatment results, including mortality. This study was conducted to estimate treatment outcomes and adverse effects in patients with drug-resistant TB on a bedaquiline-containing regimen. Patients after the pre-treatment evaluation were enrolled in a bedaquiline-containing regimen. These patients were followed up for 18 months, and the final outcome was assessed along with the adverse effects. It was found that 49 (84.4%) patients achieved culture conversion by 3 months, 54 (93.1%) achieved culture conversion by 6 months, 52 (83.81%) had favorable outcomes (cured, treatment completed), and 10 had unfavorable outcomes (died, lost to follow-up, failed). Coupled with gradually increasing trends in success rates since 2012, lesser failure rates and fewer concerns regarding grave adverse effects are a silver lining in the cloud of increasing burden and widening resistance patterns. More funding has to be directed towards ensuring adherence and finding high-risk individuals to expedite the achievement of sustainable development goals.
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Affiliation(s)
| | - Suman Khangarot
- Department of Respiratory Medicine, Government Medical College, Kota.
| | | | - Anish Mittal
- Department of Respiratory Medicine, Government Medical College, Kota.
| | - Ramdhan Somani
- Department of Respiratory Medicine, Government Medical College, Kota.
| | - Mansha Grover
- Department of Respiratory Medicine, Government Medical College, Kota.
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3
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Pai H, Ndjeka N, Mbuagbaw L, Kaniga K, Birmingham E, Mao G, Alquier L, Davis K, Bodard A, Williams A, Van Tongel M, Thoret-Bauchet F, Omar SV, Bakare N. Bedaquiline safety, efficacy, utilization and emergence of resistance following treatment of multidrug-resistant tuberculosis patients in South Africa: a retrospective cohort analysis. BMC Infect Dis 2022; 22:870. [DOI: 10.1186/s12879-022-07861-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 11/09/2022] [Indexed: 11/23/2022] Open
Abstract
Abstract
Background
This retrospective cohort study assessed benefits and risks of bedaquiline treatment in multidrug-resistant-tuberculosis (MDR-TB) combination therapy by evaluating safety, effectiveness, drug utilization and emergence of resistance to bedaquiline.
Methods
Data were extracted from a register of South African drug-resistant-tuberculosis (DR-TB) patients (Electronic DR-TB Register [EDRWeb]) for newly diagnosed patients with MDR-TB (including pre-extensively drug-resistant [XDR]-TB and XDR-TB and excluding rifampicin-mono-resistant [RR]-TB, as these patients are by definition not multidrug-resistant), receiving either a bedaquiline-containing or non-bedaquiline-containing regimen, at 14 sites in South Africa. Total duration of treatment and follow-up was up to 30 months, including 6 months’ bedaquiline treatment. WHO treatment outcomes within 6 months after end-of-treatment were assessed in both patient groups. Longer term mortality (up to 30 months from treatment start) was evaluated through matching to the South African National Vital Statistics Register. Multivariable Cox proportional hazards analyses were used to predict association between receiving a bedaquiline-containing regimen and treatment outcome.
Results
Data were extracted from EDRWeb for 5981 MDR-TB patients (N = 3747 bedaquiline-treated; N = 2234 non-bedaquiline-treated) who initiated treatment between 2015 and 2017, of whom 40.7% versus 80.6% had MDR-TB. More bedaquiline-treated than non-bedaquiline-treated patients had pre-XDR-TB (27.7% versus 9.5%) and XDR-TB (31.5% versus 9.9%) per pre-2021 WHO definitions. Most patients with treatment duration data (94.3%) received bedaquiline for 6 months. Treatment success (per pre-2021 WHO definitions) was achieved in 66.9% of bedaquiline-treated and 49.4% of non-bedaquiline-treated patients. Death was reported in fewer bedaquiline-treated (15.4%) than non-bedaquiline-treated (25.6%) patients. Bedaquiline-treated patients had increased likelihood of treatment success and decreased risk of mortality versus non-bedaquiline-treated patients. In patients with evaluable drug susceptibility testing data, 3.5% of bedaquiline-susceptible isolates at baseline acquired phenotypic resistance. Few patients reported bedaquiline-related treatment-emergent adverse events (TEAEs) (1.8%), TEAE-related bedaquiline discontinuations (1.4%) and QTcF values > 500 ms (2.5%) during treatment.
Conclusion
Data from this large cohort of South African patients with MDR-TB showed treatment with bedaquiline-containing regimens was associated with survival and effectiveness benefit compared with non-bedaquiline-containing regimens. No new safety signals were detected. These data are consistent with the positive risk–benefit profile of bedaquiline and warrant continued implementation in combination therapy for MDR-TB treatment.
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Bedaquiline-based treatment for extensively drug-resistant tuberculosis in South Africa: A cost-effectiveness analysis. PLoS One 2022; 17:e0272770. [PMID: 35930574 PMCID: PMC9355220 DOI: 10.1371/journal.pone.0272770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/26/2022] [Indexed: 11/22/2022] Open
Abstract
Background The treatment success rate of conventional anti-tuberculosis (TB) regimens for extensively drug-resistant TB (XDR-TB) is low, resulting in high morbidity and healthcare cost especially in the high TB burden countries. Recent clinical findings reported improved treatment outcomes of XDR-TB with the bedaquiline (BDQ)-based regimens. We aimed to evaluate the cost-effectiveness of BDQ-based treatment for XDR-TB from the perspective of the South Africa national healthcare provider. Methods A 2-year decision-analytic model was designed to evaluate the clinical and economic outcomes of a hypothetical cohort of adult XDR-TB patients with (1) BDQ-based regimen and (2) injectable-based conventional regimen. The model inputs were retrieved from literature and public data. Base-case analysis and sensitivity analysis were performed. The primary model outputs included TB-related direct medical cost and disability-adjusted life years (DALYs). Results In the base-case analysis, the BDQ group reduced 4.4152 DALYs with an incremental cost of USD1,606 when compared to the conventional group. The incremental cost per DALY averted (ICER) by the BDQ group was 364 USD/DALY averted. No influential factor was identified in the sensitivity analysis. In probabilistic sensitivity analysis, the BDQ group was accepted as cost-effective in 97.82% of the 10,000 simulations at a willingness-to-pay threshold of 5,656 USD/DALY averted (1× gross domestic product per capita in South Africa). Conclusion The BDQ-based therapy appeared to be cost-effective and showed a high probability to be accepted as the preferred cost-effective option for active XDR-TB treatment.
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Pediatric Tuberculosis Management: A Global Challenge or Breakthrough? CHILDREN 2022; 9:children9081120. [PMID: 36010011 PMCID: PMC9406656 DOI: 10.3390/children9081120] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/19/2022] [Accepted: 07/23/2022] [Indexed: 12/17/2022]
Abstract
Managing pediatric tuberculosis (TB) remains a public health problem requiring urgent and long-lasting solutions as TB is one of the top ten causes of ill health and death in children as well as adolescents universally. Minors are particularly susceptible to this severe illness that can be fatal post-infection or even serve as reservoirs for future disease outbreaks. However, pediatric TB is the least prioritized in most health programs and optimal infection/disease control has been quite neglected for this specialized patient category, as most scientific and clinical research efforts focus on developing novel management strategies for adults. Moreover, the ongoing coronavirus pandemic has meaningfully hindered the gains and progress achieved with TB prophylaxis, therapy, diagnosis, and global eradication goals for all affected persons of varying age bands. Thus, the opening of novel research activities and opportunities that can provide more insight and create new knowledge specifically geared towards managing TB disease in this specialized group will significantly improve their well-being and longevity.
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Effectiveness of the Novel Anti-TB Bedaquiline against Drug-Resistant TB in Africa: A Systematic Review of the Literature. Pathogens 2022; 11:pathogens11060636. [PMID: 35745490 PMCID: PMC9229213 DOI: 10.3390/pathogens11060636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 11/23/2022] Open
Abstract
Background: In 2018, an estimated 10.0 million people contracted tuberculosis (TB), and 1.5 million died from it, including 1.25 million HIV-negative persons and 251,000 HIV-associated TB fatalities. Drug-resistant tuberculosis (DR-TB) is an important contributor to global TB mortality. Multi-drug-resistant TB (MDR-TB) is defined as TB resistant to at least isoniazid (INH) and rifampin (RMP), which are recommended by the WHO as essential drugs for treatment. Objective: To investigate the effectiveness of bedaquiline addition to the treatment of drug-resistant TB infections on the African continent. Methodology: The search engine databases Medline, PubMed, Google Scholar, and Embase were used to obtain published data pertaining to DR-TB between 2012 and 2021 in Africa. Included studies had to document clinical characteristics at treatment initiation and outcomes at the end of treatment (i.e., success, failure, recurrence, loss to follow-up, and death). The included studies were used to conduct a meta-analysis. All data analysis and visualization were performed using the R programming environment. The log risk ratios and sample variances were calculated for DR-TB patients treated with BBQ monotherapy vs. BDQ and other drug therapy. To quantify heterogeneity among the included studies, random effect sizes were calculated. Results: A total of 16 studies in Africa from Mozambique (N = 1 study), Eswatini (N = 1 study), Democratic Republic of the Congo (N = 1 study), South Africa (N = 12 studies), and a multicenter study undertaken across Africa (N = 1 study) were included. In total, 22,368 individuals participated in the research studies. Among the patients, (55.2%; 12,350/22,368) were male while 9723/22,368 (44%) were female. Overall, (9%; 2033/22,368) of patients received BDQ monotherapy, while (88%; 19,630/22,368) patients received bedaquiline combined with other antibiotics. In total, (42%; 9465/22,368) of the patients were successfully treated. About (39%; 8653/22,368) of participants finished their therapy, meanwhile (5%; 1166/22,368) did not finish their therapy, while people (0.4%; 99/22,368) were lost to follow up. A total of (42%; 9265/22,368) patients died. Conclusion: Very few studies on bedaquiline usage in DR-TB in Africa have been published to date. Bedaquiline has been shown to enhance DR-TB results in clinical studies and programmatic settings. Hence, the World Health Organization (WHO) has recommended that it be included in DR-TB regimens. However, in the current study limited improvement to DR-TB treatment results were observed using BDQ on the continent. Better in-country monitoring and reporting, as well as multi-country collaborative cohort studies of DR-TB, can expand the knowledge of bedaquiline usage and clinical impact, as well as the risks and benefits throughout the continent.
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7
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Mohr-Holland E, Daniels J, Reuter A, Rodriguez CA, Mitnick C, Kock Y, Cox V, Furin J, Cox H. Early mortality during rifampicin-resistant TB treatment. Int J Tuberc Lung Dis 2022; 26:150-157. [PMID: 35086627 PMCID: PMC8802559 DOI: 10.5588/ijtld.21.0494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/30/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND: Data suggest that treatment with newer TB drugs (linezolid [LZD], bedaquiline [BDQ] and delamanid [DLM]), used in Khayelitsha, South Africa, since 2012, reduces mortality due to rifampicin-resistant TB (RR-TB).METHODS: This was a retrospective cohort study to assess 6-month mortality among RR-TB patients diagnosed between 2008 and 2019.RESULTS: By 6 months, 236/2,008 (12%) patients died; 12% (78/651) among those diagnosed in 2008-2011, and respectively 8% (49/619) and 15% (109/738) with and without LZD/BDQ/DLM in 2012-2019. Multivariable analysis showed a small, non-significant mortality reduction with LZD/BDQ/DLM use compared to the 2008-2011 period (aOR 0.79, 95% CI 0.5-1.2). Inpatient treatment initiation (aOR 3.2, 95% CI 2.4-4.4), fluoroquinolone (FQ) resistance (aOR 2.7, 95% CI 1.8-4.2) and female sex (aOR 1.5, 95% CI 1.1-2.0) were also associated with mortality. When restricted to 2012-2019, use of LZD/BDQ/DLM was associated with lower mortality (aOR 0.58, 95% CI 0.39-0.87).CONCLUSIONS: While LZD/BDQ/DLM reduced 6-month mortality between 2012 and 2019, there was no significant effect overall. These findings may be due to initially restricted LZD/BDQ/DLM use for those with high-level resistance or treatment failure. Additional contributors include increased treatment initiation among individuals who would have otherwise died before treatment due to universal drug susceptibility testing from 2012, an effect that also likely contributed to higher mortality among females (survival through to care-seeking).
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Affiliation(s)
- E Mohr-Holland
- Khayelitsha Project, Médecins Sans Frontières (MSF), Cape Town, South Africa, Southern Africa Medical Unit, MSF, Cape Town, South Africa
| | - J Daniels
- Khayelitsha Project, Médecins Sans Frontières (MSF), Cape Town, South Africa
| | - A Reuter
- Khayelitsha Project, Médecins Sans Frontières (MSF), Cape Town, South Africa
| | - C A Rodriguez
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - C Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Y Kock
- National Department of Health, Pretoria, South Africa
| | - V Cox
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - J Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - H Cox
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa, Institute for Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town, Cape Town, South Africa
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Das M, Dalal A, Laxmeshwar C, Ravi S, Mamnoon F, Meneguim AC, Paryani R, Mathur T, Singh P, Mansoor H, Kalon S, Hossain FN, Lachenal N, Coutisson S, Ferlazzo G, Isaakidis P. One Step Forward: Successful End-of-Treatment Outcomes of Patients With Drug-Resistant Tuberculosis Who Received Concomitant Bedaquiline and Delamanid in Mumbai, India. Clin Infect Dis 2021; 73:e3496-e3504. [PMID: 33079176 DOI: 10.1093/cid/ciaa1577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/14/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Médecins Sans Frontières Clinic in Mumbai, India, has been providing concomitant bedaquiline (BDQ) and delamanid (DLM) in treatment regimen for patients with drug-resistant tuberculosis (DR-TB) and limited therapeutic options, referred from other healthcare institutions, since 2016. The study documents the end-of-treatment outcomes, culture-conversion rates, and serious adverse events (SAEs) during treatment. METHODS This was a retrospective cohort study based on routinely collected program data. In clinic, treatment regimens are designed based on culture drug sensitivity test patterns and previous drug exposures, and are provided for 20-22 months. BDQ and DLM are extended beyond 24 weeks as off-label use. Patients who initiated DR-TB treatment including BDQ and DLM (concomitantly for at least 4 weeks) during February 2016-February 2018 were included. RESULTS Of the 70 patients included, the median age was 25 (interquartile range [IQR], 22-32) years and 56% were females. All except 1 were fluoroquinolone resistant. The median duration of exposure to BDQ and DLM was 77 (IQR, 43-96) weeks. Thirty-nine episodes of SAEs were reported among 30 (43%) patients, including 5 instances of QTc prolongation, assessed as possibly related to BDQ and/or DLM. The majority (69%) had culture conversion before 24 weeks of treatment. In 61 (87%), use of BDQ and DLM was extended beyond 24 weeks. Successful end-of-treatment outcomes were reported in 49 (70%) patients. CONCLUSIONS The successful treatment outcomes of this cohort show that regimens including concomitant BDQ and DLM for longer than 24 weeks are effective and can be safely administered on an ambulatory basis. National TB programs globally should scale up access to life-saving DR-TB regimens with new drugs.
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Affiliation(s)
| | - Alpa Dalal
- Jupiter Hospital, Thane, Maharashtra, India
| | | | | | | | | | | | | | | | | | | | | | - Nathalie Lachenal
- Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | - Sylvine Coutisson
- Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | - Gabriella Ferlazzo
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Petros Isaakidis
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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9
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Isralls S, Baisley K, Ngam E, Grant AD, Millard J. QT Interval Prolongation in People Treated With Bedaquiline for Drug-Resistant Tuberculosis Under Programmatic Conditions: A Retrospective Cohort Study. Open Forum Infect Dis 2021; 8:ofab413. [PMID: 34466629 PMCID: PMC8403230 DOI: 10.1093/ofid/ofab413] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/30/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Bedaquiline has a black-box warning of the risk of arrhythmias and sudden death. This study aimed to determine the incidence of QTc prolongation and cardiac events in patients receiving bedaquiline for drug-resistant tuberculosis (DR-TB) under programmatic conditions. METHODS Retrospective cohort study of patients receiving bedaquiline at a DR-TB hospital in KwaZulu Natal, South Africa from September 2017 to February 2019. The primary outcome, a prolonged QT interval corrected using the Fridericia formula (QTcF), was defined as QTcF >500 ms, QTcF change >60 ms from baseline, or both. RESULTS Among 420 patients (66.2% male, median age 36 years), the median QTcF was 406.4 (interquartile range [IQR], 389.1-421.3) ms at baseline, increasing to 430.5 (IQR, 414.4-445.1) ms by 3 months and 434.0 (IQR, 419.0-447.9) ms at 6 months. Eighteen of 420 patients (4.3%) had a QTcF >500 ms and 110 of 420 patients (26.2%) had a QTcF change >60 ms. There were no recorded arrhythmias or cardiac deaths. Odds of prolonged QTcF were increased with concomitant azoles (adjusted odds ratio [aOR], 5.61 [95% confidence interval (CI), 2.26-13.91]; P < .001) and an inverse association with HIV-positive status (aOR, 0.34 [95% CI, .15-.75]; P = .008) and hypertension (aOR, 0.13 [95% CI, .02-.86]; P = .02). After prolongation, the QTcF declined to <500 ms, whether drugs were interrupted or not. CONCLUSIONS We observed a modest prolongation of QTcF, maximal at week 15; there were no recorded arrhythmias or related deaths.
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Affiliation(s)
- Sharon Isralls
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kathy Baisley
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Africa Health Research Institute, Durban, South Africa
| | - Eric Ngam
- University of KwaZulu-Natal, Durban, South Africa
| | - Alison D Grant
- Africa Health Research Institute, Durban, South Africa
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - James Millard
- Africa Health Research Institute, Durban, South Africa
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, Liverpool, United Kingdom
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
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Khan PY, Franke MF, Hewison C, Seung KJ, Huerga H, Atwood S, Ahmed S, Khan M, Sultana T, Manzur-Ul-Alam M, Vo LNQ, Lecca L, Yae K, Kozhabekov S, Tamirat M, Gelin A, Vilbrun SC, Kikvidze M, Faqirzai J, Kadyrov A, Skrahina A, Mesic A, Avagyan N, Bastard M, Rich ML, Khan U, Mitnick CD. All-oral longer regimens are effective for the management of multidrug resistant tuberculosis in high burden settings. Eur Respir J 2021; 59:13993003.04345-2020. [PMID: 34140298 DOI: 10.1183/13993003.04345-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 05/31/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recent World Health Organisation guidance on drug-resistant tuberculosis treatment de-prioritised injectable agents, in use for decades, and endorsed all-oral longer regimens. However, questions remain about the role of the injectable agent, particularly in the context of regimens using new and repurposed drugs. We compared the effectiveness of an injectable-containing regimen to that of an all-oral regimen among patients with drug-resistant tuberculosis who received bedaquiline- and/or delamanid as part of their multidrug regimen. METHODS Patients with a positive baseline culture were included. Six-month culture conversion was defined as two consecutive negative cultures collected >15 days apart. We derived predicted probabilities of culture conversion and relative risk using marginal standardisation methods. RESULTS Culture conversion was observed in 83.8% (526/628) of patients receiving an all-oral regimen and 85.5% (425/497) of those receiving an injectable-containing regimen. The adjusted relative risk comparing injectable-containing regimens to all-oral regimens was 0.96 (95%CI: 0.88-1.04). We found very weak evidence of effect modification by HIV status: among patients living with HIV, there was a small increase in the frequency of conversion among those receiving an injectable-containing regimen, relative to an all-oral regimen, which was not apparent in HIV-negative patients. CONCLUSIONS Among individuals receiving bedaquiline and/or delamanid as part of a multidrug regimen for drug-resistant tuberculosis, there was no significant difference between those who received an injectable and those who did not regarding culture conversion within 6 months. The potential contribution of injectable agents in the treatment of drug-resistant tuberculosis among those who were HIV positive requires further study.
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Affiliation(s)
- Palwasha Y Khan
- Interactive Research and Development Global, Singapore ; .,Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,These authors contributed equally
| | - Molly F Franke
- Partners In Health, Boston, USA.,Department of Global Health and Social Medicine, Harvard Medical School.,These authors contributed equally
| | | | - Kwonjune J Seung
- Partners In Health, Boston, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA
| | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA
| | - Saman Ahmed
- Interactive Research and Development, Karachi, Pakistan
| | - Munira Khan
- Interactive Research and Development, Durban, South Africa
| | - Tanha Sultana
- Interactive Research and Development, Dhaka, Bangladesh
| | | | - Luan N Q Vo
- Interactive Research and Development Global, Singapore.,Friends for International TB Relief, Ho Chi Minh City, Viet Nam
| | | | - Kalkidan Yae
- Partners In Health, Ethiopia, Addis Ababa, Ethiopia
| | | | | | | | - Stalz C Vilbrun
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | | | | | | | - Anita Mesic
- Médecins Sans Frontières, Amsterdam, Holland
| | - Nana Avagyan
- Medical Department, Médecins Sans Frontières, Paris, France
| | | | - Michael L Rich
- Partners In Health, Boston, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA
| | - Uzma Khan
- Interactive Research and Development Global, Singapore.,These authors contributed equally
| | - Carole D Mitnick
- Partners In Health, Boston, USA.,Department of Global Health and Social Medicine, Harvard Medical School.,These authors contributed equally
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11
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Chesov D, Heyckendorf J, Alexandru S, Donica A, Chesov E, Reimann M, Crudu V, Botnaru V, Lange C. Impact of bedaquiline on treatment outcomes of multidrug-resistant tuberculosis in a high-burden country. Eur Respir J 2021; 57:13993003.02544-2020. [PMID: 33334942 DOI: 10.1183/13993003.02544-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/23/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND Evaluation of novel anti-tuberculosis (TB) drugs for the treatment of multidrug-resistant (MDR)-TB continues to be of high interest on the TB research agenda. We assessed treatment outcomes in patients with pulmonary MDR-TB who received bedaquiline-containing treatment regimens in the Republic of Moldova, a high-burden MDR-TB country. METHOD We systematically analysed the SIMETB national electronic TB database and performed a retrospective propensity score-matched comparison of treatment outcomes in a cohort of patients with MDR-TB who started treatment during 2016-2018 with a bedaquiline-containing regimen (bedaquiline cohort) and a cohort of patients treated without bedaquiline (non-bedaquiline cohort). RESULTS Following propensity score matching, 114 patients were assigned to each cohort of MDR-TB patients. Patients in the bedaquiline cohort had a higher 6-month sputum culture conversion rate than those in the non-bedaquiline cohort (66.7% versus 40.3%; p<0.001). Patients under bedaquiline-containing regimens had a higher cure rate assessed by both World Health Organization (WHO) and TBnet definitions (55.3% versus 24.6%; p=0.001 and 43.5% versus 19.6%; p=0.004, respectively), as well as a lower mortality rate (8.8% versus 20.2%; p<0.001 and 10.9% versus 25.2%; p=0.01, respectively). In patients who previously failed on MDR-TB treatment, >40% of patients achieved a cure with a bedaquiline-containing regimen. CONCLUSIONS Bedaquiline-based MDR-TB treatment regimens result in better disease resolution when compared with bedaquiline-sparing MDR-TB treatment regimens under programmatic conditions in a country with a high burden of MDR-TB.
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Affiliation(s)
- Dumitru Chesov
- Dept of Pneumology and Allergology, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova .,Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | - Jan Heyckendorf
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany.,Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany
| | - Sofia Alexandru
- National TB Reference Laboratory, Chiril Draganiuc Phthisiopneumology Institute, Chisinau, Republic of Moldova
| | - Ana Donica
- National TB Reference Laboratory, Chiril Draganiuc Phthisiopneumology Institute, Chisinau, Republic of Moldova
| | - Elena Chesov
- Dept of Pneumology and Allergology, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova.,Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
| | - Maja Reimann
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | - Valeriu Crudu
- National TB Reference Laboratory, Chiril Draganiuc Phthisiopneumology Institute, Chisinau, Republic of Moldova
| | - Victor Botnaru
- Dept of Pneumology and Allergology, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany.,Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany
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12
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Padayatchi N, Bionghi N, Osman F, Naidu N, Ndjeka N, Master I, Brust JCM, Naidoo K, Ramjee A, O Donnell M. Treatment outcomes in patients with drug-resistant TB-HIV co-infection treated with bedaquiline and linezolid. Int J Tuberc Lung Dis 2021; 24:1024-1031. [PMID: 33126934 DOI: 10.5588/ijtld.20.0048] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: Bedaquiline (BDQ) has not been extensively studied among patients co-infected with HIV drug-resistant tuberculosis (DR-TB). We compared treatment outcomes in DR-TB patients treated with BDQ- and linezolid (LZD) containing regimens to historic controls treated with second-line injectable-containing regimens.METHODS: Retrospective cohort study of consecutive DR-TB patients initiated on BDQ- and LZD-containing regimens at a TB referral hospital in KwaZulu-Natal, South Africa. Participants were prospectively followed through 24 months for treatment outcome and adverse events. Outcomes were compared to a historic control cohort of DR-TB HIV patients enrolled at the same facility prior to BDQ introduction.RESULTS: Adult DR-TB patients initiating BDQ between January 2014 and November 2015 were enrolled (n = 151). The majority of patients were female (52%), HIV co-infected (77%) and on antiretroviral therapy (100%). End of treatment outcomes included cure (63%), TB culture conversion (83%), completion (0.7%), loss to follow-up (15%), treatment failure (5%), and death (17%). Compared to historic controls (n = 105), patients treated with BDQ experienced significantly higher TB culture conversion and cure, with significantly lower mortality. Adverse effects were common (92%), and most frequently attributed to LZD (24.1%). QT segment prolongation was common but without clinical sequelae.CONCLUSION: Treatment with BDQ- and LZD-containing regimens was associated with improved treatment outcomes and survival in DR-TB HIV patients.
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Affiliation(s)
- N Padayatchi
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, College of Health Sciences, Medical Research Council-Centre for the AIDS Program of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Congella, South Africa
| | - N Bionghi
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - F Osman
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, College of Health Sciences, Medical Research Council-Centre for the AIDS Program of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Congella, South Africa
| | - N Naidu
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, College of Health Sciences, Medical Research Council-Centre for the AIDS Program of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Congella, South Africa
| | - N Ndjeka
- National TB Programme, South African National Department of Health, Pretoria
| | - I Master
- King DinuZulu Medical Complex, Sydenham, South Africa
| | - J C M Brust
- Divisions of General Internal Medicine and Infectious Diseases, Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, NY
| | - K Naidoo
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, College of Health Sciences, Medical Research Council-Centre for the AIDS Program of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Congella, South Africa
| | - A Ramjee
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, College of Health Sciences, Medical Research Council-Centre for the AIDS Program of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Congella, South Africa
| | - M O Donnell
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, College of Health Sciences, Medical Research Council-Centre for the AIDS Program of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Congella, South Africa, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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13
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Kielmann K, Dickson-Hall L, Jassat W, Le Roux S, Moshabela M, Cox H, Grant AD, Loveday M, Hill J, Nicol MP, Mlisana K, Black J. 'We had to manage what we had on hand, in whatever way we could': adaptive responses in policy for decentralized drug-resistant tuberculosis care in South Africa. Health Policy Plan 2021; 36:249-259. [PMID: 33582787 PMCID: PMC8059133 DOI: 10.1093/heapol/czaa147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 11/16/2022] Open
Abstract
In 2011, the South African National TB Programme launched a policy of decentralized management of drug-resistant tuberculosis (DR-TB) in order to expand the capacity of facilities to treat patients with DR-TB, minimize delays to access care and improve patient outcomes. This policy directive was implemented to varying degrees within a rapidly evolving diagnostic and treatment landscape for DR-TB, placing new demands on already-stressed health systems. The variable readiness of district-level systems to implement the policy prompted questions not only about differences in health systems resources but also front-line actors' capacity to implement change in resource-constrained facilities. Using a grounded theory approach, we analysed data from in-depth interviews and small group discussions conducted between 2016 and 2018 with managers (n = 9), co-ordinators (n = 15), doctors (n = 7) and nurses (n = 18) providing DR-TB care. Data were collected over two phases in district-level decentralized sites of three South African provinces. While health systems readiness assessments conventionally map the availability of 'hardware', i.e. resources and skills to deliver an intervention, a notable absence of systems 'hardware' meant that systems 'software', i.e. health care workers (HCWs) agency, behaviours and interactions provided the basis of locally relevant strategies for decentralized DR-TB care. 'Software readiness' was manifest in four areas of DR-TB care: re-organization of service delivery, redressal of resource shortages, creation of treatment adherence support systems and extension of care parameters for vulnerable patients. These strategies demonstrate adaptive capacity and everyday resilience among HCW to withstand the demands of policy change and innovation in stressed systems. Our work suggests that a useful extension of health systems 'readiness' assessments would include definition and evaluation of HCW 'software' and adaptive capacities in the face of systems hardware gaps.
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Affiliation(s)
- Karina Kielmann
- Institute of Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Lindy Dickson-Hall
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
| | | | - Sacha Le Roux
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
| | - Mosa Moshabela
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
| | - Helen Cox
- Institute for Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town, Cape Town, South Africa
| | - Alison D Grant
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, TB Centre, UK
- School of Public Health, University of the Witwatersrand, South Africa
| | - Marian Loveday
- Health Systems Research Unit, South African Medical Research Council
| | - Jeremy Hill
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
- London School of Hygiene & Tropical Medicine, TB Centre, UK
| | - Mark P Nicol
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
- Infection and Immunity, School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Koleka Mlisana
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - John Black
- Department of Infectious Diseases, Livingstone Hospital, Lindsay Rd, Industrial, Port Elizabeth, 6020, South Africa
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14
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Bedaquiline: Current status and future perspectives. J Glob Antimicrob Resist 2021; 25:48-59. [PMID: 33684606 DOI: 10.1016/j.jgar.2021.02.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/28/2021] [Accepted: 02/17/2021] [Indexed: 12/21/2022] Open
Abstract
The development of drug-resistant tuberculosis (TB) is a major threat worldwide. Based on World Health Organization (WHO) reports, it is estimated that more than 500 000 new cases of drug-resistant TB occur annually. In addition, there are alarming reports of increasing multidrug-resistant TB (MDR-TB) and the emergence of extensively drug-resistant TB (XDR-TB) from different countries of the world. Therefore, new options for TB therapy are required. Bedaquiline (BDQ), a novel anti-TB drug, has significant minimum inhibitory concentrations (MICs) both against drug-susceptible and drug-resistant TB. Moreover, BDQ was recently approved for therapy of MDR-TB. The current narrative review summarises the available data on BDQ resistance, describes its antimicrobial properties, and provides new perspectives on clinical use of this novel anti-TB agent.
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15
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Are We There Yet? Short-Course Regimens in TB and HIV: From Prevention to Treatment of Latent to XDR TB. Curr HIV/AIDS Rep 2021; 17:589-600. [PMID: 32918195 DOI: 10.1007/s11904-020-00529-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW Despite broad uptake of antiretroviral therapy (ART), tuberculosis (TB) incidence and mortality among people with HIV remain unacceptably high. Short-course regimens for TB, incorporating both novel and established drugs, offer the potential to enhance adherence and completion rates, thereby reducing the global TB burden. This review will outline short-course regimens for TB among patients with HIV. RECENT FINDINGS After many years without new agents, there is now active testing of many novel drugs to treat TB, both for latent infection and active disease. Though not all studies have included patients with HIV, many have, and there are ongoing trials to address key implementation challenges such as potent drug-drug interactions with ART. The goal of short-course regimens for TB is to enhance treatment completion without compromising efficacy. Particularly among patients with HIV, studying these shortened regimens and integrating them into clinical care are of urgent importance. There are now multiple short-course regimens for latent infection and active disease that are safe and effective among patients with HIV.
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16
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de Araújo RV, Santos SS, Sanches LM, Giarolla J, El Seoud O, Ferreira EI. Malaria and tuberculosis as diseases of neglected populations: state of the art in chemotherapy and advances in the search for new drugs. Mem Inst Oswaldo Cruz 2020; 115:e200229. [PMID: 33053077 PMCID: PMC7534959 DOI: 10.1590/0074-02760200229] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/04/2020] [Indexed: 11/22/2022] Open
Abstract
Malaria and tuberculosis are no longer considered to be neglected diseases by the World Health Organization. However, both are huge challenges and public health problems in the world, which affect poor people, today referred to as neglected populations. In addition, malaria and tuberculosis present the same difficulties regarding the treatment, such as toxicity and the microbial resistance. The increase of Plasmodium resistance to the available drugs along with the insurgence of multidrug- and particularly tuberculosis drug-resistant strains are enough to justify efforts towards the development of novel medicines for both diseases. This literature review provides an overview of the state of the art of antimalarial and antituberculosis chemotherapies, emphasising novel drugs introduced in the pharmaceutical market and the advances in research of new candidates for these diseases, and including some aspects of their mechanism/sites of action.
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Affiliation(s)
- Renan Vinicius de Araújo
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas,
Departamento de Farmácia, Laboratório de Planejamento e Síntese de Quimioterápicos
Contra Doenças Negligenciadas, São Paulo, SP, Brasil
| | - Soraya Silva Santos
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas,
Departamento de Farmácia, Laboratório de Planejamento e Síntese de Quimioterápicos
Contra Doenças Negligenciadas, São Paulo, SP, Brasil
| | - Luccas Missfeldt Sanches
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas,
Departamento de Farmácia, Laboratório de Planejamento e Síntese de Quimioterápicos
Contra Doenças Negligenciadas, São Paulo, SP, Brasil
| | - Jeanine Giarolla
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas,
Departamento de Farmácia, Laboratório de Planejamento e Síntese de Quimioterápicos
Contra Doenças Negligenciadas, São Paulo, SP, Brasil
| | - Omar El Seoud
- Universidade de São Paulo, Instituto de Química, Departamento de
Química Fundamental, São Paulo, SP, Brasil
| | - Elizabeth Igne Ferreira
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas,
Departamento de Farmácia, Laboratório de Planejamento e Síntese de Quimioterápicos
Contra Doenças Negligenciadas, São Paulo, SP, Brasil
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17
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Murhula Kashongwe I, Mawete F, Anshambi N, Maingowa N, Aloni M, Lukaso L'osenga L, Kaswa M, Munogolo Kashongwe Z. Challenge to treat pre-extensively drug-resistant tuberculosis in a low-income country: A report of 12 cases. J Clin Tuberc Other Mycobact Dis 2020; 21:100192. [PMID: 33024840 PMCID: PMC7527706 DOI: 10.1016/j.jctube.2020.100192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Setting: Democratic Republic of the Congo is a high-burden TB country. Its capital, Kinshasa, reports annually about one-third of all MDR-TB cases in the country; thus, pre-XDRTB management is warranted. Objectives To describe the main challenges in treating pre- XDR TB in this low resources setting and possible solutions. Method This is a retrospective study of all pre-XDR TB patients diagnosed in Kinshasa in 2018. A personalized regimen was applied according to the clinical profile, drug availability, and the Drug susceptibility testing (DST). Treatment was administered by hospitalization during the intensive phase and in ambulatory care in the continuation phase except in emergencies. Monthly follow up included evaluating clinical and bacteriological features, renal and liver functions, QT interval on ECG, and audiometry for those under aminoglycosides. Results Among the 236 MDR-TB patients identified in 2018, 14 had pre-XDR. Two died before treatment initiation. Of the remaining 12. 75% were male, 50% were aged 25-44 years, 66.7% had previous anti-tuberculosis treatment, 75% had a body mass index < 18.5 kg/m2, and 1 patient was HIV positive. On radiography, all the patients had cavities. The median time from the diagnosis to treatment initiation was 48.5 days (range: 14-105). A favorable outcome occurred in 10 cases (83.3%), one patient died, and anotherwas lost to follow up. Nine (75%) patients reported adverse reactions, which were mild or moderate in 6 cases and severe in 2 cases. The severe reactions were psychosis (1 case) and ototoxicity (1 case). Conclusion Successful pre-XDRTB treatment using the new strategy is possible even in a low-income country. The main challenges are diagnosis access, drug availability and follow-up laboratory facilities. These can be included in a global policy review by the NTP to ensure the sustainability of the strategies implemented.
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Affiliation(s)
- Innocent Murhula Kashongwe
- Internal Medicine, Pulmonology Unit, Kinshasa University Hospital, Kinshasa, Democratic Republic of the Congo.,Drug-Resistant Tuberculosis Unit 'Centre d'excellence Damien', Damian Foundation, Kinshasa, Democratic Republic of the Congo.,National Tuberculosis Program of the Democratic Republic of the Congo, Democratic Republic of the Congo
| | - Fina Mawete
- National Tuberculosis Program of the Democratic Republic of the Congo, Democratic Republic of the Congo
| | - Nicole Anshambi
- Provincial Coordination for Tuberculosis Control, Kinshasa, Democratic Republic of the Congo
| | - Nadine Maingowa
- Provincial Coordination for Tuberculosis Control, Kinshasa, Democratic Republic of the Congo
| | - Murielle Aloni
- National Laboratory of Mycobacteria, Kinshasa, Democratic Republic of the Congo
| | - Luc Lukaso L'osenga
- Drug-Resistant Tuberculosis Unit 'Centre d'excellence Damien', Damian Foundation, Kinshasa, Democratic Republic of the Congo
| | - Michel Kaswa
- National Tuberculosis Program of the Democratic Republic of the Congo, Democratic Republic of the Congo.,National Laboratory of Mycobacteria, Kinshasa, Democratic Republic of the Congo
| | - Zacharie Munogolo Kashongwe
- Internal Medicine, Pulmonology Unit, Kinshasa University Hospital, Kinshasa, Democratic Republic of the Congo
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18
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Outcomes and adverse events of pre- and extensively drug-resistant tuberculosis patients in Kinshasa, Democratique Republic of the Congo: A retrospective cohort study. PLoS One 2020; 15:e0236264. [PMID: 32750060 PMCID: PMC7402497 DOI: 10.1371/journal.pone.0236264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 07/01/2020] [Indexed: 11/30/2022] Open
Abstract
Background Extensively drug-resistant tuberculosis (XDR TB) is a very serious form of tuberculosis that is burdened with a heavy mortality toll, especially before the advent of new TB drugs. The Democratic Republic of the Congo (DRC) is among the countries most affected by this new epidemic. Methods A retrospective analysis was performed of the records of all patients with pre- and extensively drug-resistant tuberculosis hospitalized from January 1, 2015 to December 31, 2017 and monitored for at least 6 months to one year after the end of their treatment in Kinshasa; an individualized therapeutic regimen with bedaquiline for 20 months was built for each patient. The adverse effects were systematically monitored. Results Of the 40 laboratory-confirmed patients, 32 (80%) patients started treatment, including 29 preXRB and 3 XDR TB patients. In the eligible group, 3 patients (9.4%) had HIV-TB coinfections. The therapeutic success rate was 53.2%, and the mortality rate was 46.8% (15/32); there were no relapses, failures or losses to follow-up. All coinfected HIV–TB patients died during treatment. The cumulative patient survival rate was 62.5% at 3 months, 53.1% at 6 months and 53.1% at 20 months. The most common adverse events were vomiting, Skin rash, anemia and peripheral neuropathy. Conclusion The new anti-tuberculosis drugs are a real hope for the management of Drug Resistant tuberculosis patient and other new therapeutic combinations may improve favorable outcomes.
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19
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Pai S, Muruganandah V, Kupz A. What lies beneath the airway mucosal barrier? Throwing the spotlight on antigen-presenting cell function in the lower respiratory tract. Clin Transl Immunology 2020; 9:e1158. [PMID: 32714552 PMCID: PMC7376394 DOI: 10.1002/cti2.1158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/22/2020] [Accepted: 06/26/2020] [Indexed: 12/12/2022] Open
Abstract
The global prevalence of respiratory infectious and inflammatory diseases remains a major public health concern. Prevention and management strategies have not kept pace with the increasing incidence of these diseases. The airway mucosa is the most common portal of entry for infectious and inflammatory agents. Therefore, significant benefits would be derived from a detailed understanding of how immune responses regulate the filigree of the airways. Here, the role of different antigen‐presenting cells (APC) in the lower airways and the mechanisms used by pathogens to modulate APC function during infectious disease is reviewed. Features of APC that are unique to the airways and the influence they have on uptake and presentation of antigen to T cells directly in the airways are discussed. Current information on the crucial role that airway APC play in regulating respiratory infection is summarised. We examine the clinical implications of APC dysregulation in the airways on asthma and tuberculosis, two chronic diseases that are the major cause of illness and death in the developed and developing world. A brief overview of emerging therapies that specifically target APC function in the airways is provided.
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Affiliation(s)
- Saparna Pai
- Centre for Molecular Therapeutics Australian Institute of Tropical Health and Medicine James Cook University Cairns QLD Australia
| | - Visai Muruganandah
- Centre for Molecular Therapeutics Australian Institute of Tropical Health and Medicine James Cook University Cairns QLD Australia
| | - Andreas Kupz
- Centre for Molecular Therapeutics Australian Institute of Tropical Health and Medicine James Cook University Cairns QLD Australia
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20
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Guglielmetti L, Chiesi S, Eimer J, Dominguez J, Masini T, Varaine F, Veziris N, Ader F, Robert J. Bedaquiline and delamanid for drug-resistant tuberculosis: a clinician's perspective. Future Microbiol 2020; 15:779-799. [PMID: 32700565 DOI: 10.2217/fmb-2019-0309] [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] [Indexed: 11/21/2022] Open
Abstract
Drug-resistant tuberculosis (TB) represents a substantial threat to the global efforts to control this disease. After decades of stagnation, the treatment of drug-resistant TB is undergoing major changes: two drugs with a new mechanism of action, bedaquiline and delamanid, have been approved by stringent regulatory authorities and are recommended by the WHO. This narrative review summarizes the evidence, originating from both observational studies and clinical trials, which is available to support the use of these drugs, with a focus on special populations. Areas of uncertainty, including the use of the two drugs together or for prolonged duration, are discussed. Ongoing clinical trials are aiming to optimize the use of bedaquiline and delamanid to shorten the treatment of drug-resistant TB.
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Affiliation(s)
- Lorenzo Guglielmetti
- APHP, Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, F-75013 Paris, France.,Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, équipe 2, F-75013, Paris, France.,Médecins Sans Frontières, France
| | - Sheila Chiesi
- Department of Infectious Diseases, 'GB Rossi' Hospital, Verona, Italy.,University of Verona, Verona, Italy
| | - Johannes Eimer
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Jose Dominguez
- Research Institute Germans Trias i Pujol, CIBER Respiratory Diseases, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | | | - Nicolas Veziris
- Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, équipe 2, F-75013, Paris, France.,APHP, Département de Bactériologie, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux (CNR-MyRMA), Hôpitaux Universitaires de l'Est Parisien, F-75012, Paris, France
| | - Florence Ader
- Département des Maladies infectieuses et tropicales, Hospices Civils de Lyon, F-69004, Lyon, France.,Centre International de Recherche en Infectiologie (CIRI), Inserm 1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007 Lyon, France
| | - Jérôme Robert
- APHP, Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, F-75013 Paris, France.,Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, équipe 2, F-75013, Paris, France
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21
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Dheda K, Gumbo T, Maartens G, Dooley KE, Murray M, Furin J, Nardell EA, Warren RM. The Lancet Respiratory Medicine Commission: 2019 update: epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant and incurable tuberculosis. THE LANCET RESPIRATORY MEDICINE 2020; 7:820-826. [PMID: 31486393 DOI: 10.1016/s2213-2600(19)30263-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 01/23/2023]
Abstract
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.
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Affiliation(s)
- Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African Medical Research Council/University of Cape Town Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK.
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Megan Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; T H Chan School of Public Health, Harvard Medical School, Boston, MA, USA
| | - Edward A Nardell
- T H Chan School of Public Health, Harvard Medical School, Boston, MA, USA
| | - Robin M Warren
- South African Medical Research Council Centre for Tuberculosis Research/Department of Science and Technology/ National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
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22
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Zhao Y, Fox T, Manning K, Stewart A, Tiffin N, Khomo N, Leslie J, Boulle A, Mudaly V, Kock Y, Meintjes G, Wasserman S. Improved Treatment Outcomes With Bedaquiline When Substituted for Second-line Injectable Agents in Multidrug-resistant Tuberculosis: A Retrospective Cohort Study. Clin Infect Dis 2020; 68:1522-1529. [PMID: 30165431 DOI: 10.1093/cid/ciy727] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 08/21/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Bedaquiline is used as a substitute for second-line injectable (SLI) intolerance in the treatment of multidrug-resistant (MDR) tuberculosis, but the efficacy and safety of this strategy is unknown. METHODS In this retrospective cohort study adults receiving bedaquiline substitution for MDR tuberculosis therapy, plus a matched control group who did not receive bedaquiline, were identified from the electronic tuberculosis register in the Western Cape Province, South Africa. The primary outcome measure was the proportion of patients with death, loss to follow-up, or failure to achieve sustained culture conversion at 12 months of treatment. RESULTS Data from 162 patients who received bedaquiline substitution and 168 controls were analyzed; 70.6% were infected with human immunodeficiency virus. Unfavorable outcomes occurred in 35 of 146 (23.9%) patients in the bedaquiline group versus 51 of 141 (36.2%) in the control group (relative risk, 0.66; 95% confidence interval, .46 -.95). The number of patients with culture reversion was lower in those receiving bedaquiline (1 patient; 0.8%) than in controls (12 patients; 10.3%; P = .001). Delayed initiation of bedaquiline was independently associated with failure to achieve sustained culture conversion (adjusted odds ratio for every 30-day delay, 1.5; 95% confidence interval, 1.1-1.9). Mortality rates were similar at 12 months (11 deaths in each group; P = .97). CONCLUSIONS Substituting bedaquiline for SLIs in MDR tuberculosis treatment resulted in improved outcomes at 12 months compared with patients who continued taking SLIs, supporting the use of bedaquiline for MDR tuberculosis treatment in programmatic settings.
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Affiliation(s)
- Ying Zhao
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamaryn Fox
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kathryn Manning
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Annemie Stewart
- Clinical Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Nicki Tiffin
- Provincial Health Data Centre, Western Cape Department of Health and Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Computational Biology, Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ntokozo Khomo
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Joshua Leslie
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Provincial Health Data Centre, Western Cape Department of Health and Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Vanessa Mudaly
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Yulene Kock
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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23
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Barvaliya SV, Desai MK, Panchal JR, Solanki RN. Early treatment outcome of bedaquiline plus optimised background regimen in drug resistant tuberculosis patients. Indian J Tuberc 2020; 67:222-230. [PMID: 32553316 DOI: 10.1016/j.ijtb.2020.03.002] [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: 07/29/2019] [Revised: 11/20/2019] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
Abstract
AIMS Bedaquiline (BDQ) has been recently approved for drug resistant tuberculosis with active drug safety monitoring under programmatic condition. The present study was conducted to evaluate safety, tolerability and efficacy of bedaquiline plus optimised background regimen. METHODS A prospective study was conducted on cohort of pre-extensively drug resistant (XDR) and XDR pulmonary TB patients. Eligible patients were closely monitored for cardiac safety, adverse events (AEs), clinical and microbiological improvement during BDQ (6 months) and post BDQ phase for twelve months. RESULTS Of 127 patients enrolled, a significant increase in mean QTc interval was observed on 13th day and 3rd week as compared to baseline (p < 0.0001). Mean maximum increase of QTc was 37.92ms (95% CI, 14.1-61.74ms). Concomitant anti-TB medications, age, gender, low body mass index (BMI) had significant effect on QTc prolongation (p < 0.0001, p < 0.05). However, none of the patient required discontinuation of BDQ. Majority of AEs (86.3%) were non-serious and not preventable 108 (87.1%). The median time for sputum-culture conversion was 40.89 ± 3.5 days (95% CI, 34-48 days) and the treatment outcome was successful in 102 (80.3%) patients with negative sputum culture conversion. CONCLUSIONS Bedaquiline containing regimen achieved favourable outcome. Although, bedaquiline along with concomitant anti-TB medications has the potential to prolong QTc interval, the benefit certainly outweighs the risk. This calls for a through pre-treatment cardiovascular and biochemical evaluation as a preventive measure and appropriate selection of patients for safe use of BDQ and successful outcome.
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Affiliation(s)
- Sandip V Barvaliya
- Department of Pharmacology, B. J. Medical College & Civil Hospital, Ahmedabad, 380016, India
| | - Mira K Desai
- Department of Pharmacology, B. J. Medical College & Civil Hospital, Ahmedabad, 380016, India
| | - Jigar R Panchal
- Department of Pharmacology, B. J. Medical College & Civil Hospital, Ahmedabad, 380016, India.
| | - Rajesh N Solanki
- Department of Pulmonary Medicine, B. J. Medical College & Civil Hospital, Ahmedabad, 380016, India
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24
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Triple Mycobacterial ATP-synthase mutations impedes Bedaquiline binding: Atomistic and structural perspectives. Comput Biol Chem 2020; 85:107204. [DOI: 10.1016/j.compbiolchem.2020.107204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 01/06/2020] [Accepted: 01/13/2020] [Indexed: 01/07/2023]
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25
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Abidi S, Achar J, Assao Neino MM, Bang D, Benedetti A, Brode S, Campbell JR, Casas EC, Conradie F, Dravniece G, du Cros P, Falzon D, Jaramillo E, Kuaban C, Lan Z, Lange C, Li PZ, Makhmudova M, Maug AKJ, Menzies D, Migliori GB, Miller A, Myrzaliev B, Ndjeka N, Noeske J, Parpieva N, Piubello A, Schwoebel V, Sikhondze W, Singla R, Souleymane MB, Trébucq A, Van Deun A, Viney K, Weyer K, Zhang BJ, Ahmad Khan F. Standardised shorter regimens versus individualised longer regimens for rifampin- or multidrug-resistant tuberculosis. Eur Respir J 2020; 55:13993003.01467-2019. [PMID: 31862767 DOI: 10.1183/13993003.01467-2019] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 12/04/2019] [Indexed: 11/05/2022]
Abstract
We sought to compare the effectiveness of two World Health Organization (WHO)-recommended regimens for the treatment of rifampin- or multidrug-resistant (RR/MDR) tuberculosis (TB): a standardised regimen of 9-12 months (the "shorter regimen") and individualised regimens of ≥20 months ("longer regimens").We collected individual patient data from observational studies identified through systematic reviews and a public call for data. We included patients meeting WHO eligibility criteria for the shorter regimen: not previously treated with second-line drugs, and with fluoroquinolone- and second-line injectable agent-susceptible RR/MDR-TB. We used propensity score matched, mixed effects meta-regression to calculate adjusted odds ratios and adjusted risk differences (aRDs) for failure or relapse, death within 12 months of treatment initiation and loss to follow-up.We included 2625 out of 3378 (77.7%) individuals from nine studies of shorter regimens and 2717 out of 13 104 (20.7%) individuals from 53 studies of longer regimens. Treatment success was higher with the shorter regimen than with longer regimens (pooled proportions 80.0% versus 75.3%), due to less loss to follow-up with the former (aRD -0.15, 95% CI -0.17- -0.12). The risk difference for failure or relapse was slightly higher with the shorter regimen overall (aRD 0.02, 95% CI 0-0.05) and greater in magnitude with baseline resistance to pyrazinamide (aRD 0.12, 95% CI 0.07-0.16), prothionamide/ethionamide (aRD 0.07, 95% CI -0.01-0.16) or ethambutol (aRD 0.09, 95% CI 0.04-0.13).In patients meeting WHO criteria for its use, the standardised shorter regimen was associated with substantially less loss to follow-up during treatment compared with individualised longer regimens and with more failure or relapse in the presence of resistance to component medications. Our findings support the need to improve access to reliable drug susceptibility testing.
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Affiliation(s)
- Syed Abidi
- McGill International TB Centre, Montreal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Jay Achar
- Médecins Sans Frontières/Doctors without Borders, London, UK
| | | | - Didi Bang
- International Reference Laboratory of Mycobacteriology, National Centre for Antimicrobials and Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - Andrea Benedetti
- McGill International TB Centre, Montreal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Dept of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Sarah Brode
- West Park Healthcare Centre, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Jonathon R Campbell
- McGill International TB Centre, Montreal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Esther C Casas
- Médecins Sans Frontières/Doctors without Borders, Amsterdam, The Netherlands
| | - Francesca Conradie
- Dept of Medicine, University of Witswatersrand, Johannesburg, South Africa
| | | | - Philipp du Cros
- Médecins Sans Frontières/Doctors without Borders, London, UK.,Burnet Institute, Melbourne, Australia
| | | | | | - Christopher Kuaban
- Faculty of Health Sciences, The University of Bamenda, Bambili, Cameroon
| | - Zhiyi Lan
- McGill International TB Centre, Montreal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Christoph Lange
- Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,German Center for Infection Research Clinical TB Unit, Borstel, Germany.,Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany.,Dept of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Pei Zhi Li
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | | | - Dick Menzies
- McGill International TB Centre, Montreal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Giovanni Battista Migliori
- WHO Collaborating Centre for Tuberculosis and Lung Diseases, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | - Ann Miller
- Dept of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Bakyt Myrzaliev
- KNCV TB Foundation, Branch Office KNCV in Kyrgyzstan, Bishkek, Kyrgyzstan
| | - Norbert Ndjeka
- National TB Programme, Republic of South Africa, Pretoria, South Africa
| | | | | | - Alberto Piubello
- Damien Foundation, Brussels, Belgium.,International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Valérie Schwoebel
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Welile Sikhondze
- National TB Control Program, Eswatini Ministry of Health, Mbabane, Swaziland
| | - Rupak Singla
- National Institute of Tuberculosis and Respiratory Diseases, Delhi, India
| | | | - Arnaud Trébucq
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Armand Van Deun
- Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kerri Viney
- The University of Sydney, Sydney, Australia.,Karolinska Institutet, Stockholm, Sweden.,Australian National University, Canberra, Australia
| | - Karin Weyer
- World Health Organization, Geneva, Switzerland
| | - Betty Jingxuan Zhang
- McGill International TB Centre, Montreal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Faiz Ahmad Khan
- McGill International TB Centre, Montreal, QC, Canada .,Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada
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26
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Mpobela Agnarson A, Williams A, Kambili C, Mattson G, Metz L. The cost-effectiveness of a bedaquiline-containing short-course regimen for the treatment of multidrug-resistant tuberculosis in South Africa. Expert Rev Anti Infect Ther 2020; 18:475-483. [PMID: 32186925 DOI: 10.1080/14787210.2020.1742109] [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] [Indexed: 10/24/2022]
Abstract
Background: Bedaquiline-containing regimens have demonstrated improved outcomes over injectable-containing regimens in the long-term treatment of multidrug-resistant tuberculosis (MDR-TB). Recently, the World Health Organization (WHO) recommended replacing injectables in the standard short-course regimen (SCR) with a bedaquiline-containing regimen. The South African national TB program similarly recommends a bedaquiline-containing regimen. Here, we investigated the cost-effectiveness of a bedaquiline-containing SCR versus an injectable-containing SCR for the treatment of MDR-TB in South Africa.Methods: A Markov model was adapted to simulate the incidence of active patients with MDR-TB. Patients could transition through eight health states: active MDR-TB, culture conversion, cure, follow-up loss, secondary MDR-TB, extensively DR-TB, end-of-life care, and death. A 5% discount was assumed on costs and outcomes. Health outcomes were expressed as disability-adjusted life years (DALYs).Results: Over a 10-year time horizon, a bedaquiline-containing SCR dominated an injectable-containing SCR, with an incremental saving of US $982 per DALY averted. A bedaquiline-containing SCR was associated with lower total costs versus an injectable-containing SCR (US $597 versus $657 million), of which US $3.2 versus $21.9 million was attributed to adverse event management.Conclusions: Replacing an injectable-containing SCR with a bedaquiline-containing SCR is cost-effective, offering a cost-saving alternative with improved patient outcomes for MDR-TB.
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Affiliation(s)
| | - Abeda Williams
- Janssen Pharmaceutical South Africa, Pharmaceutical Division of Johnson and Johnson, Johannesburg, South Africa
| | | | - Gunnar Mattson
- Johnson & Johnson Global Public Health, New Brunswick, NJ, USA
| | - Laurent Metz
- Johnson & Johnson Global Public Health, New Brunswick, NJ, USA
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27
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Kim JH, Kwon OJ, Kim YS, Park MS, Hwang S, Shim TS. Bedaquiline in multidrug-resistant tuberculosis treatment: Safety and efficacy in a Korean subpopulation. Respir Investig 2019; 58:45-51. [PMID: 31635903 DOI: 10.1016/j.resinv.2019.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/31/2019] [Accepted: 08/21/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND The final treatment outcomes of Korean multidrug-resistant tuberculosis (MDR-TB) patients treated with bedaquiline in the C209 trial have not yet been reported. Therefore, a subgroup analysis of the Korean population from the C209 trial was performed, and the results were compared with those of the overall C209 study population. METHODS In the C209 trial, MDR-TB patients were treated with bedaquiline for 24 weeks in combination with background anti-TB drugs, and were followed-up until week 120 after bedaquiline treatment initiation. RESULTS With the exception of drug susceptibility patterns, the baseline clinical characteristics of both groups were similar. The proportions of pre-extensively drug-resistant TB to extensively drug-resistant TB (pre-XDR-TB/XDR-TB) were 61.9 and 35.2% in the Korean and the overall C209 populations, respectively. Aminoglycosides, later-generation fluoroquinolones, cycloserine, and linezolid were the most common concomitant drugs used during bedaquiline treatment. The culture conversion rates of both groups were similar at week 24 (end of bedaquiline treatment; 80.0% vs. 79.5%) and 120 (75.0% vs. 72.2%). Additionally, the frequency and type of adverse events during treatment were similar in both groups, and 1 patient (5.0%) died due to a cause unrelated to bedaquiline treatment. CONCLUSIONS Bedaquiline showed similar efficacy and safety in Korean patients with MDR-TB, despite their advanced drug-resistance profiles, possibly due to other concomitant drugs such as linezolid.
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Affiliation(s)
- Ji Hyun Kim
- Janssen Korea, Ltd., 25F LS Yongsan Tower, 92 Hangang-Daero, Yongsan-Gu, Seoul, 04386, Republic of Korea.
| | - O Jung Kwon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Republic of Korea.
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University, College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University, College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
| | - Sungchul Hwang
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, 164 World Cup-Ro, Yeongtong-Gu, Suwon, Gyeonggi, 16499, Republic of Korea.
| | - Tae Sun Shim
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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28
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Salhotra VS, Sachdeva KS, Kshirsagar N, Parmar M, Ramachandran R, Padmapriyadarsini C, Patel Y, Mehandru L, Jaju J, Ponnuraja C, Gupta M, Kalaiselvan V, Shamim A, Khaparde S, Swaminathan S. Effectiveness and safety of bedaquiline under conditional access program for treatment of drug-resistant tuberculosis in India: An interim analysis. Indian J Tuberc 2019; 67:29-37. [PMID: 32192613 DOI: 10.1016/j.ijtb.2019.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND India accounts for a quarter of the world's multidrug-resistant tuberculosis (MDR-TB); with less than 50% having successful treatment outcomes. Bedaquiline (BDQ) was approved for use under conditional access program in India in 2015. OBJECTIVE We evaluate the effectiveness, safety, and tolerability of a BDQ containing regimen used under field settings in India. METHOD Interim analysis of a prospective cohort of MDR-TB patients on a BDQ containing regimen at six sites in the country. RESULTS Six hundred and twenty MDR-TB patients [349 (56%) males; 554 (89%) between 18 and 50 years and 240 (39%) severely malnourished] were started on BDQ containing regimen between June 2016 and August 2017. There 354 (57%) patients had MDR-TB with additional drug resistance to fluoroquinolone (MDRFQ); 31 (5%) with additional resistance to second-line injectable (MDRSLI) and 101 (16%) extensively drug-resistant TB. After 6 months of treatment, culture conversion was achieved in 513 of 620 (83%) patients. The median time to culture conversion was 60 days. Higher body mass index was the only factor associated with faster culture conversion (HR 1.97; 95% CI 1.24-2.9). Around 100 patients (16.3%) experienced a ≥60-ms increase in QTc interval during the treatment. Seventy-three (12%) deaths were reported, the majority of them (56%) occurring within the first 6 months of treatment. CONCLUSIONS BDQ with a background regimen has the potential to achieve higher and faster culture conversion rates with a lower toxicity profile among DR-TB patients. Use of BDQ with additional monitoring may be safe and effective even in the field settings.
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Affiliation(s)
- V S Salhotra
- Central TB Division, Ministry of Health and Family Welfare, India.
| | - K S Sachdeva
- Central TB Division, Ministry of Health and Family Welfare, India.
| | - Neelima Kshirsagar
- Clinical Pharmacology, Indian Council of Medical Research, New Delhi, India.
| | | | | | | | - Yogesh Patel
- Central TB Division, Ministry of Health and Family Welfare, India.
| | - Lalit Mehandru
- Central TB Division, Ministry of Health and Family Welfare, India.
| | - Jyoti Jaju
- Central TB Division, Ministry of Health and Family Welfare, India.
| | - C Ponnuraja
- ICMR, National Institute for Research in Tuberculosis, Chennai, India.
| | | | - V Kalaiselvan
- Indian Pharmacopoeia Commission, Ministry of Health & Family Welfare, India.
| | - Almas Shamim
- Central TB Division, Ministry of Health and Family Welfare, India.
| | - S Khaparde
- Central TB Division, Ministry of Health and Family Welfare, India.
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29
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Tiemersma E, van den Hof S, Dravniece G, Wares F, Molla Y, Permata Y, Lukitosari E, Quelapio M, Aung ST, Aung KM, Thuy HT, Hoa VD, Sulaimanova M, Sagyndikova S, Makhmudova M, Soliev A, Kimerling M. Integration of drug safety monitoring in tuberculosis treatment programmes: country experiences. Eur Respir Rev 2019; 28:28/153/180115. [PMID: 31604816 DOI: 10.1183/16000617.0115-2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 09/09/2019] [Indexed: 11/05/2022] Open
Abstract
New drugs and shorter treatments for drug-resistant tuberculosis (DR-TB) have become available in recent years and active pharmacovigilance (PV) is recommended by the World Health Organization (WHO) at least during the early phases of implementation, with active drug safety monitoring and management (aDSM) proposed for this. We conducted a literature review of papers reporting on aDSM. Up to 18 April, 2019, results have only been published from one national aDSM programme. Because aDSM is being introduced in many low- and middle-income countries, we also report experiences in introducing it into DR-TB treatment programmes, targeting the reporting of a restricted set of adverse events (AEs) as per WHO-recommended aDSM principles for the period 2014-2017. Early beneficial effects of active PV for TB patients include increased awareness about the occurrence, detection and management of AEs during TB treatment, and the increase of spontaneous reporting in some countries. However, because PV capacity is low in most countries and collaboration between national TB programmes and national PV centres remains weak, parallel and coordinated co-development of the capacities of both TB programmes and PV centres is needed.
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Affiliation(s)
| | - Susan van den Hof
- KNCV Tuberculosis Foundation, Den Haag, the Netherlands.,Centre for Infectious Disease Epidemiology and Surveillance, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | | | - Fraser Wares
- KNCV Tuberculosis Foundation, Den Haag, the Netherlands
| | | | | | - Endang Lukitosari
- National Tuberculosis Program, Ministry of Health, Jakarta, Indonesia
| | | | - Si Thu Aung
- Dept of Public Health, Ministry of Health and Sports, Yangon, Myanmar
| | | | - Hoang Thanh Thuy
- National Tuberculosis Program, Ministry of Health, Hanoi, Vietnam
| | - Vu Dinh Hoa
- National Centre of Drug Information and Adverse Drug Reactions & Hanoi University of Pharmacy, Hanoi, Vietnam
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30
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Taune M, Ustero P, Hiashiri S, Huang K, Aia P, Morris L, Main S, Chan G, du Cros P, Majumdar SS. Successful implementation of bedaquiline for multidrug-resistant TB treatment in remote Papua New Guinea. Public Health Action 2019; 9:S73-S79. [PMID: 31579654 PMCID: PMC6735455 DOI: 10.5588/pha.18.0071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 04/12/2019] [Indexed: 11/10/2022] Open
Abstract
SETTING Bedaquiline (BDQ) was introduced in the multi-drug-resistant tuberculosis (MDR-TB) programme in Daru in remote Papua New Guinea in 2015, along with a core package of active drug-safety monitoring (aDSM). OBJECTIVE To assess interim results and safety of BDQ for the treatment of MDR-TB from 1 July 2015 to 31 December 2017. DESIGN A retrospective cohort analysis of routine programme data. RESULTS Of 277 MDR-TB patients, 77 (39%) received BDQ with a total of 8 serious adverse events including 5 (6.5%) deaths, of which 1 (1.3% QTcF prolongation, grade 3) was attributable to BDQ. Of 200 (61%) patients who did not receive BDQ, there were 17 (9%) deaths. Completeness of monitoring for the BDQ group was 90% for >5 electrocardiograms and 79% for ⩾2 cultures. In the interim result indicator analysis at month 6 in the BDQ and non-BDQ groups, there were respectively 0% and 1% lost to follow-up; 6.5% and 8.5% who died; 94% and 91% in care; and 92% and 96% with negative culture among those monitored. CONCLUSION Early experience in Daru shows BDQ is safe and feasible to implement with aDSM with good interim effectiveness supporting the rapid adoption and scale-up of the 2019 WHO MDR-TB treatment guidelines in the programme and in similar remote settings.
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Affiliation(s)
- M Taune
- Daru General Hospital, Daru, Western Province, Papua New Guinea
| | - P Ustero
- Burnet Institute, Melbourne, Victoria, Australia
| | - S Hiashiri
- Burnet Institute, Melbourne, Victoria, Australia
| | - K Huang
- Burnet Institute, Melbourne, Victoria, Australia
| | - P Aia
- National TB Program, Port Moresby, Papua New Guinea
| | - L Morris
- Provincial Health Office, Daru, Western Province, Papua New Guinea
| | - S Main
- Burnet Institute, Melbourne, Victoria, Australia
| | - G Chan
- Burnet Institute, Melbourne, Victoria, Australia
| | - P du Cros
- Burnet Institute, Melbourne, Victoria, Australia
| | - S S Majumdar
- Burnet Institute, Melbourne, Victoria, Australia
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31
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Lange C, Dheda K, Chesov D, Mandalakas AM, Udwadia Z, Horsburgh CR. Management of drug-resistant tuberculosis. Lancet 2019; 394:953-966. [PMID: 31526739 DOI: 10.1016/s0140-6736(19)31882-3] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/08/2019] [Accepted: 07/18/2019] [Indexed: 12/11/2022]
Abstract
Drug-resistant tuberculosis is a major public health concern in many countries. Over the past decade, the number of patients infected with Mycobacterium tuberculosis resistant to the most effective drugs against tuberculosis (ie, rifampicin and isoniazid), which is called multidrug-resistant tuberculosis, has continued to increase. Globally, 4·6% of patients with tuberculosis have multidrug-resistant tuberculosis, but in some areas, like Kazakhstan, Kyrgyzstan, Moldova, and Ukraine, this proportion exceeds 25%. Treatment for patients with multidrug-resistant tuberculosis is prolonged (ie, 9-24 months) and patients with multidrug-resistant tuberculosis have less favourable outcomes than those treated for drug-susceptible tuberculosis. Individualised multidrug-resistant tuberculosis treatment with novel (eg, bedaquiline) and repurposed (eg, linezolid, clofazimine, or meropenem) drugs and guided by genotypic and phenotypic drug susceptibility testing can improve treatment outcomes. Some clinical trials are evaluating 6-month regimens to simplify management and improve outcomes of patients with multidrug-resistant tuberculosis. Here we review optimal diagnostic and treatment strategies for patients with drug-resistant tuberculosis and their contacts.
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Affiliation(s)
- Christoph Lange
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany; German Center for Infection Research Clinical Tuberculosis Unit, Borstel, Germany; Department of Medicine, Karolinska Institute, Stockholm, Sweden.
| | - Keertan Dheda
- Department of Medicine, Division of Pulmonology, Centre for Lung Infection and Immunity, Lung Institute, and Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; South African Medical Research Council, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - Dumitru Chesov
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; Department of Pneumology and Alergollogy, Nicoale Testemitanu State University of Medicine and Pharmacy, Chisinau, Moldova
| | - Anna Maria Mandalakas
- The Global Tuberculosis Programme, Texas Children's Hospital, and Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Zarir Udwadia
- Hinduja Hospital and Research Center, Veer Savarkar Marg, Mumbai, India
| | - C Robert Horsburgh
- Department of Medicine, School of Medicine, and Department of Epidemiology, Department of Biostatistics, and Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
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32
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Abstract
Tuberculosis (TB) is a major issue in global health and affects millions of people each year. Multidrug-resistant tuberculosis (MDR-TB) annually causes many deaths worldwide. Development of a way to diagnose and treat patients with MDR-TB can potentially reduce the incidence of the disease. The current study reviews the risk factors, pattern of progression, mechanism of resistance, and interaction between bacteria and the host immune system, which disrupts the immune response. It also targets the components of Mycobacterium tuberculosis (Mtb) and diagnosis and treatment options that could be available for clinical use in the near future. Mutations play an important role in development of MDR-TB and the selection of appropriate mutations can help to understand the type of resistance in patients to anti-TB drugs. In this way, they can be initially treated with proper and effective therapeutic choices, which can accelerate the course of treatment and improve patient health. Targeting the components and enzymes of Mtb is necessary for understanding bacterial survival and finding a way to destroy the pathogen and allow patients to recover faster and prevent the spread of disease, especially resistant strains.
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Affiliation(s)
- Majid Faridgohar
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran.,Department of Microbiology and Immunology, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
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33
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Cohen K, Maartens G. A safety evaluation of bedaquiline for the treatment of multi-drug resistant tuberculosis. Expert Opin Drug Saf 2019; 18:875-882. [DOI: 10.1080/14740338.2019.1648429] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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34
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Jones J, Mudaly V, Voget J, Naledi T, Maartens G, Cohen K. Adverse drug reactions in South African patients receiving bedaquiline-containing tuberculosis treatment: an evaluation of spontaneously reported cases. BMC Infect Dis 2019; 19:544. [PMID: 31221100 PMCID: PMC6585062 DOI: 10.1186/s12879-019-4197-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 06/17/2019] [Indexed: 11/25/2022] Open
Abstract
Background Bedaquiline was recently introduced into World Health Organization (WHO)-recommended regimens for treatment of drug resistant tuberculosis. There is limited data on the long-term safety of bedaquiline. Because bedaquiline prolongs the QT interval, there are concerns regarding cardiovascular safety. The Western Cape Province in South Africa has an established pharmacovigilance programme: a targeted spontaneous reporting system which solicits reports of suspected adverse drug reactions (ADRs) in patients with HIV-1 and/or tuberculosis infection. Since 2015, bedaquiline has been included in the treatment regimens recommended for resistant tuberculosis in South Africa. We describe ADRs in patients on bedaquiline-containing tuberculosis treatment that were reported to the Western Cape Pharmacovigilance programme. Methods We reviewed reports of suspected ADRs and deaths received between March 2015 and June 2016 involving patients receiving bedaquiline-containing tuberculosis treatment. A multidisciplinary panel assessed causality, and categorised suspected ADRs using World Health Organisation-Uppsala Monitoring Centre system categories. “Confirmed ADRs” included all ADRs categorised as definite, probable or possible. Preventability was assessed using Schumock and Thornton criteria. Where a confirmed ADR occurred in a patient who died, the panel categorised the extent to which the ADR contributed to the patient’s death as follows: major contributor, contributor or non-contributor. Results Thirty-five suspected ADRs were reported in 32 patients, including 13 deaths. There were 30 confirmed ADRs, of which 23 were classified as “possible” and seven as “probable”. Bedaquiline was implicated in 22 confirmed ADRs in 22 patients. The most common confirmed ADR in patients receiving bedaquiline was QT prolongation (8 cases, 7 of which were severe). A fatal arrhythmia was suspected in 4 sudden deaths. These 4 patients were all taking bedaquiline together with other QT-prolonging drugs. There were 8 non-bedaquiline-associated ADRs, of which 7 contributed to deaths. Conclusions Confirmed ADRs in patients receiving bedaquiline reflect the known safety profile of bedaquiline. Quantifying the incidence and clinical consequences of severe QT-prolongation in patients receiving bedaquiline-containing regimens is a research priority to inform recommendations for patient monitoring in treatment programmes for drug resistant tuberculosis. Pharmacovigilance systems within tuberculosis treatment programmes should be supported and encouraged, to provide ongoing monitoring of treatment-limiting drug toxicity.
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Affiliation(s)
- Jackie Jones
- Medicines Information Centre, Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, K45, Old Main Building, Groote Schuur Hospital, Observatory, Cape Town, 7945, South Africa
| | - Vanessa Mudaly
- Health Programmes, Department of Health, Western Cape Government 1st Floor, Norton Rose House, 8 Riebeek Street, Cape Town, 8000, South Africa
| | - Jacqueline Voget
- Health Programmes, Department of Health, Western Cape Government 1st Floor, Norton Rose House, 8 Riebeek Street, Cape Town, 8000, South Africa
| | - Tracey Naledi
- Health Programmes, Department of Health, Western Cape Government 1st Floor, Norton Rose House, 8 Riebeek Street, Cape Town, 8000, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Falmouth Rd, Observatory, Cape Town, 7945, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, K45, Old Main Building, Groote Schuur Hospital, Observatory, Cape Town, 7945, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, K45, Old Main Building, Groote Schuur Hospital, Observatory, Cape Town, 7945, South Africa.
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35
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Salifu EY, Agoni C, Olotu FA, Dokurugu YM, Soliman MES. Halting ionic shuttle to disrupt the synthetic machinery-Structural and molecular insights into the inhibitory roles of Bedaquiline towards Mycobacterium tuberculosis ATP synthase in the treatment of tuberculosis. J Cell Biochem 2019; 120:16108-16119. [PMID: 31125144 DOI: 10.1002/jcb.28891] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/26/2019] [Accepted: 03/15/2019] [Indexed: 12/31/2022]
Abstract
Therapeutic targeting of the adenosine triphosphate (ATP) machinery of Mycobacterium tuberculosis (Mtb) has recently presented a potent and alternative measure to halt the pathogenesis of tuberculosis. This has been potentiated by the development of bedaquiline (BDQ), a novel small molecule inhibitor that selectively inhibits mycobacterial F1 Fo -ATP synthase by targeting its rotor c-ring, resulting in the disruption of ATP synthesis and consequential cell death. Although the structural resolution of the mycobacterial C9 ring in co`mplex with BDQ provided the first-hand detail of BDQ interaction at the c-ring region of the ATP synthase, there still remains a need to obtain essential and dynamic insights into the mechanistic activity of this drug molecule towards crucial survival machinery of Mtb. As such, for the first time, we report an atomistic model to describe the structural dynamics that explicate the experimentally reported antagonistic features of BDQ in halting ion shuttling by the mycobacterial c-ring, using molecular dynamics simulation and the Molecular Mechanics/Poisson-Boltzmann Surface Area methods. Results showed that BDQ exhibited a considerably high ΔG while it specifically maintained high-affinity interactions with Glu65B and Asp32B , blocking their crucial roles in proton binding and shuttling, which is required for ATP synthesis. Moreover, the bulky nature of BDQ induced a rigid and compact conformation of the rotor c-ring, which impedes the essential rotatory motion that drives ion exchange and shuttling. In addition, the binding affinity of a BDQ molecule was considerably increased by the complementary binding of another BDQ molecule, which indicates that an increase in BDQ molecule enhances inhibitory potency against Mtb ATP synthase. Taken together, findings provide atomistic perspectives into the inhibitory mechanisms of BDQ coupled with insights that could enhance the structure-based design of novel ATP synthase inhibitors towards the treatment of tuberculosis.
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Affiliation(s)
- Elliasu Y Salifu
- Molecular Bio-computation and Drug Design Laboratory, Discipline of Pharmaceutical Chemistry, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Clement Agoni
- Molecular Bio-computation and Drug Design Laboratory, Discipline of Pharmaceutical Chemistry, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Fisayo A Olotu
- Molecular Bio-computation and Drug Design Laboratory, Discipline of Pharmaceutical Chemistry, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Yussif M Dokurugu
- College of Pharmacy & Pharmaceutical Sciences, Institute of Public Health, Florida Agricultural & Mechanical University, Tallahassee, Florida
| | - Mahmoud E S Soliman
- Molecular Bio-computation and Drug Design Laboratory, Discipline of Pharmaceutical Chemistry, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
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36
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Kendall EA, Sahu S, Pai M, Fox GJ, Varaine F, Cox H, Cegielski JP, Mabote L, Vassall A, Dowdy DW. What will it take to eliminate drug-resistant tuberculosis? Int J Tuberc Lung Dis 2019; 23:535-546. [PMID: 31097060 PMCID: PMC6600801 DOI: 10.5588/ijtld.18.0217] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Drug-resistant tuberculosis (DR-TB) is challenging to diagnose, treat, and prevent, but this situation is slowly changing. If the world is to drastically reduce the incidence of DR-TB, we must stop creating new DR-TB as an essential first step. The DR-TB epidemic that is ongoing should also be directly addressed. First-line drug resistance must be rapidly detected using universal molecular testing for resistance to at least rifampin and, preferably, other key drugs at initial TB diagnosis. DR-TB treatment outcomes must also improve dramatically. Effective use of currently available, new, and repurposed drugs, combined with patient-centered treatment that aids adherence and reduces catastrophic costs, are essential. Innovations within sight, such as short, highly effective, broadly indicated regimens, paired with point-of-care drug susceptibility testing, could accelerate progress in treatment outcomes. Preventing or containing resistance to second-line and novel drugs is also critical and will require high-quality systems for diagnosis, regimen selection, and treatment monitoring. Finally, earlier detection and/or prevention of DR-TB is necessary, with particular attention to airborne infection control, case finding, and preventive therapy for contacts of patients with DR-TB. Implementing these strategies can overcome the barrier that DR-TB represents for global TB elimination efforts, and could ultimately make global elimination of DR-TB (fewer than one annual case per million population worldwide) attainable. There is a strong cost-effectiveness case to support pursuing DR-TB elimination; however, achieving this goal will require substantial global investment plus political and societal commitment at national and local levels.
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Affiliation(s)
- E A Kendall
- Johns Hopkins University, Baltimore, Maryland, USA
| | - S Sahu
- Stop TB Partnership, Geneva, Switzerland
| | - M Pai
- McGill International TB Center, McGill University, Montreal, Quebec, Canada
| | - G J Fox
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - F Varaine
- Médecins Sans Frontières, Paris, France
| | - H Cox
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; **Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - L Mabote
- AIDS and Rights Alliance for Southern Africa, Cape Town, South Africa
| | - A Vassall
- London School of Hygiene & Tropical Medicine, London, UK
| | - D W Dowdy
- Johns Hopkins University, Baltimore, Maryland, USA
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37
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Abstract
Tuberculosis remains the leading cause of death from an infectious disease among adults worldwide, with more than 10 million people becoming newly sick from tuberculosis each year. Advances in diagnosis, including the use of rapid molecular testing and whole-genome sequencing in both sputum and non-sputum samples, could change this situation. Although little has changed in the treatment of drug-susceptible tuberculosis, data on increased efficacy with new and repurposed drugs have led WHO to recommend all-oral therapy for drug-resistant tuberculosis for the first time ever in 2018. Studies have shown that shorter latent tuberculosis prevention regimens containing rifampicin or rifapentine are as effective as longer, isoniazid-based regimens, and there is a promising vaccine candidate to prevent the progression of infection to the disease. But new tools alone are not sufficient. Advances must be made in providing high-quality, people-centred care for tuberculosis. Renewed political will, coupled with improved access to quality care, could relegate the morbidity, mortality, and stigma long associated with tuberculosis, to the past.
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Affiliation(s)
- Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Helen Cox
- Division of Medical Microbiology and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Madhukar Pai
- McGill International Tuberculosis Centre, McGill University, Montreal, QC, Canada; Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India
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38
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Sarin R, Singla N, Vohra V, Singla R, Puri M, Munjal S, Khalid U, Myneedu V, Kumar Verma A, Mathuria K. Initial experience of bedaquiline implementation under the National TB Programme at NITRD, Delhi, India. ACTA ACUST UNITED AC 2019; 66:209-213. [DOI: 10.1016/j.ijtb.2019.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/16/2019] [Indexed: 10/27/2022]
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39
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Ndjeka N, Schnippel K, Master I, Meintjes G, Maartens G, Romero R, Padanilam X, Enwerem M, Chotoo S, Singh N, Hughes J, Variava E, Ferreira H, Te Riele J, Ismail N, Mohr E, Bantubani N, Conradie F. High treatment success rate for multidrug-resistant and extensively drug-resistant tuberculosis using a bedaquiline-containing treatment regimen. Eur Respir J 2018; 52:13993003.01528-2018. [PMID: 30361246 DOI: 10.1183/13993003.01528-2018] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 10/08/2018] [Indexed: 11/05/2022]
Abstract
South African patients with rifampicin-resistant tuberculosis (TB) and resistance to fluoroquinolones and/or injectable drugs (extensively drug-resistant (XDR) and preXDR-TB) were granted access to bedaquiline through a clinical access programme with strict inclusion and exclusion criteria.PreXDR-TB and XDR-TB patients were treated with 24 weeks of bedaquiline within an optimised, individualised background regimen that could include levofloxacin, linezolid and clofazimine as needed. 200 patients were enrolled: 87 (43.9%) had XDR-TB, 99 (49.3%) were female and the median age was 34 years (interquartile range (IQR) 27-42). 134 (67.0%) were living with HIV; the median CD4+ count was 281 cells·μL-1 (IQR 130-467) and all were on antiretroviral therapy.16 out of 200 patients (8.0%) did not complete 6 months of bedaquiline: eight were lost to follow-up, six died, one stopped owing to side effects and one was diagnosed with drug-sensitive TB. 146 out of 200 patients (73.0%) had favourable outcomes: 139 (69.5%) were cured and seven (3.5%) completed treatment. 25 patients (12.5%) died, 20 (10.0%) were lost from treatment and nine (4.5%) had treatment failure. 22 adverse events were attributed to bedaquiline, including a QT interval corrected using the Fridericia formula (QTcF) >500 ms (n=5), QTcF increase >50 ms from baseline (n=11) and paroxysmal atrial flutter (n=1).Bedaquiline added to an optimised background regimen was associated with a high rate of successful treatment outcomes for this preXDR-TB and XDR-TB cohort.
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Affiliation(s)
- Norbert Ndjeka
- National TB Programme, National Dept of Health, Pretoria, South Africa
| | - Kathryn Schnippel
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Iqbal Master
- King Dinuzulu Hospital Complex, Kwazulu Natal Dept of Health, Durban, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Xavier Padanilam
- Sizwe Tropical Diseases Hospital, Gauteng Dept of Health, Johannesburg, South Africa
| | | | - Sunitha Chotoo
- King Dinuzulu Hospital Complex, Kwazulu Natal Dept of Health, Durban, South Africa
| | - Nalini Singh
- King Dinuzulu Hospital Complex, Kwazulu Natal Dept of Health, Durban, South Africa
| | - Jennifer Hughes
- Desmond Tutu TB Centre, Dept of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ebrahim Variava
- Klerksdorp Tshepong Hospital, North West Dept of Health, Klerksdorp, South Africa.,Perinatal HIV Research Unit and University of Witswatersrand, Johannesburg, South Africa
| | - Hannetjie Ferreira
- Klerksdorp Tshepong Hospital, North West Dept of Health, Klerksdorp, South Africa
| | - Julian Te Riele
- Brooklyn Chest Hospital, Western Cape Dept of Health, Cape Town, South Africa
| | - Nazir Ismail
- Centre for Tuberculosis, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa.,Dept of Medical Microbiology, University of Pretoria, Pretoria, South Africa.,Dept of Internal Medicine, University of Witwatersrand, Johannesburg, South Africa
| | - Erika Mohr
- Médecins sans Frontières, Khayelitsha, Cape Town, South Africa
| | | | - Francesca Conradie
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
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40
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Li Y, Sun F, Zhang W. Bedaquiline and delamanid in the treatment of multidrug-resistant tuberculosis: Promising but challenging. Drug Dev Res 2018; 80:98-105. [PMID: 30548290 PMCID: PMC6590425 DOI: 10.1002/ddr.21498] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/07/2018] [Accepted: 11/09/2018] [Indexed: 11/09/2022]
Abstract
Improving treatment outcomes in multidrug‐resistant tuberculosis (MDR‐TB) is partly hampered by inadequate effective antitubercular agents. Development of bedaquiline and delamanid has potentially changed the treatment landscape for MDR‐TB. This review provides an update on the progress of these novel antitubercular agents. We review published studies aimed at evaluating clinical efficacy and effectiveness of bedaquiline and delamanid. Five prospective clinical studies and seven retrospective studies on bedaquiline showed that patients treated with a bedaquiline‐containing regimen had a high culture conversion rate ranging from 65 to 100% and a satisfactory treatment outcome. The combined use with linezolid might add to the effectiveness of bedaquiline. Controversies about bedaquiline resistance are discussed. Three clinical trials have reported outcomes on delamanid and showed that introducing delamanid to a background regimen improved culture conversion rate at 2 months from 29.6% to more than 40%. A higher favorable treatment rate was also observed among patients who received delamanid for more than 6 months, but about a quarter of patients defaulted in the control group. Seven retrospective studies were summarized and found a treatment benefit as well. More reliable evidence from randomized clinical trials reporting on the treatment outcomes is needed urgently to support a strong recommendation for the use of delamanid. Advances in the combined use of bedaquiline and delamanid are also reviewed, and the combination may be well tolerated but requires electrocardiograph monitoring.
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Affiliation(s)
- Yang Li
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Feng Sun
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenhong Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China.,State Key Laboratory of Genetic Engineering, School of Life Science, Fudan University, Shanghai, China
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41
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Magis-Escurra C, Carvalho ACC, Kritski AL, Girardi E. Tuberculosis and comorbidities. Tuberculosis (Edinb) 2018. [DOI: 10.1183/2312508x.10022017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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42
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Krutikov M, Bruchfeld J, Migliori GB, Borisov S, Tiberi S. New and repurposed drugs. Tuberculosis (Edinb) 2018. [DOI: 10.1183/2312508x.10021517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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43
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Ahmad N, Ahuja SD, Akkerman OW, Alffenaar JWC, Anderson LF, Baghaei P, Bang D, Barry PM, Bastos ML, Behera D, Benedetti A, Bisson GP, Boeree MJ, Bonnet M, Brode SK, Brust JCM, Cai Y, Caumes E, Cegielski JP, Centis R, Chan PC, Chan ED, Chang KC, Charles M, Cirule A, Dalcolmo MP, D'Ambrosio L, de Vries G, Dheda K, Esmail A, Flood J, Fox GJ, Fréchet-Jachym M, Fregona G, Gayoso R, Gegia M, Gler MT, Gu S, Guglielmetti L, Holtz TH, Hughes J, Isaakidis P, Jarlsberg L, Kempker RR, Keshavjee S, Khan FA, Kipiani M, Koenig SP, Koh WJ, Kritski A, Kuksa L, Kvasnovsky CL, Kwak N, Lan Z, Lange C, Laniado-Laborín R, Lee M, Leimane V, Leung CC, Leung ECC, Li PZ, Lowenthal P, Maciel EL, Marks SM, Mase S, Mbuagbaw L, Migliori GB, Milanov V, Miller AC, Mitnick CD, Modongo C, Mohr E, Monedero I, Nahid P, Ndjeka N, O'Donnell MR, Padayatchi N, Palmero D, Pape JW, Podewils LJ, Reynolds I, Riekstina V, Robert J, Rodriguez M, Seaworth B, Seung KJ, Schnippel K, Shim TS, Singla R, Smith SE, Sotgiu G, Sukhbaatar G, Tabarsi P, Tiberi S, Trajman A, Trieu L, Udwadia ZF, van der Werf TS, Veziris N, Viiklepp P, Vilbrun SC, Walsh K, Westenhouse J, Yew WW, Yim JJ, Zetola NM, Zignol M, Menzies D. Treatment correlates of successful outcomes in pulmonary multidrug-resistant tuberculosis: an individual patient data meta-analysis. Lancet 2018; 392:821-834. [PMID: 30215381 PMCID: PMC6463280 DOI: 10.1016/s0140-6736(18)31644-1] [Citation(s) in RCA: 384] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Treatment outcomes for multidrug-resistant tuberculosis remain poor. We aimed to estimate the association of treatment success and death with the use of individual drugs, and the optimal number and duration of treatment with those drugs in patients with multidrug-resistant tuberculosis. METHODS In this individual patient data meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library to identify potentially eligible observational and experimental studies published between Jan 1, 2009, and April 30, 2016. We also searched reference lists from all systematic reviews of treatment of multidrug-resistant tuberculosis published since 2009. To be eligible, studies had to report original results, with end of treatment outcomes (treatment completion [success], failure, or relapse) in cohorts of at least 25 adults (aged >18 years). We used anonymised individual patient data from eligible studies, provided by study investigators, regarding clinical characteristics, treatment, and outcomes. Using propensity score-matched generalised mixed effects logistic, or linear regression, we calculated adjusted odds ratios and adjusted risk differences for success or death during treatment, for specific drugs currently used to treat multidrug-resistant tuberculosis, as well as the number of drugs used and treatment duration. FINDINGS Of 12 030 patients from 25 countries in 50 studies, 7346 (61%) had treatment success, 1017 (8%) had failure or relapse, and 1729 (14%) died. Compared with failure or relapse, treatment success was positively associated with the use of linezolid (adjusted risk difference 0·15, 95% CI 0·11 to 0·18), levofloxacin (0·15, 0·13 to 0·18), carbapenems (0·14, 0·06 to 0·21), moxifloxacin (0·11, 0·08 to 0·14), bedaquiline (0·10, 0·05 to 0·14), and clofazimine (0·06, 0·01 to 0·10). There was a significant association between reduced mortality and use of linezolid (-0·20, -0·23 to -0·16), levofloxacin (-0·06, -0·09 to -0·04), moxifloxacin (-0·07, -0·10 to -0·04), or bedaquiline (-0·14, -0·19 to -0·10). Compared with regimens without any injectable drug, amikacin provided modest benefits, but kanamycin and capreomycin were associated with worse outcomes. The remaining drugs were associated with slight or no improvements in outcomes. Treatment outcomes were significantly worse for most drugs if they were used despite in-vitro resistance. The optimal number of effective drugs seemed to be five in the initial phase, and four in the continuation phase. In these adjusted analyses, heterogeneity, based on a simulated I2 method, was high for approximately half the estimates for specific drugs, although relatively low for number of drugs and durations analyses. INTERPRETATION Although inferences are limited by the observational nature of these data, treatment outcomes were significantly better with use of linezolid, later generation fluoroquinolones, bedaquiline, clofazimine, and carbapenems for treatment of multidrug-resistant tuberculosis. These findings emphasise the need for trials to ascertain the optimal combination and duration of these drugs for treatment of this condition. FUNDING American Thoracic Society, Canadian Institutes of Health Research, US Centers for Disease Control and Prevention, European Respiratory Society, Infectious Diseases Society of America.
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Affiliation(s)
- Nafees Ahmad
- Faculty of Pharmacy and Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Shama D Ahuja
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, NY, USA
| | - Onno W Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands; Tuberculosis Centre Beatrixoord, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Laura F Anderson
- Global Tuberculosis Program, World Health Organization, Geneva, Switzerland
| | - Parvaneh Baghaei
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Didi Bang
- Statens Serum Institut, Copenhagen, Denmark
| | - Pennan M Barry
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, CA, USA
| | - Mayara L Bastos
- Social Medicine Institute, Epidemiology Department, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Digamber Behera
- Department of Pulmonary Medicine, World Health Organization Collaborating Centre for Research & Capacity Building in Chronic Respiratory Diseases, Chandigarh, India; Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Andrea Benedetti
- Montreal Chest Institute, McGill University Health Center Research Institute, McGill University, Montreal, QC, Canada
| | - Gregory P Bisson
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Martin J Boeree
- Department of Pulmonary Diseases, Radboud University Medicale Centre Nijmegen and Dekkerswald Radboudumc Groesbeek, Netherlands
| | - Maryline Bonnet
- Epicentre MSF, Paris, France; Institut de Recherche pour le Développement UM233, INSERM U1175, Université de Montpellier, Montpellier, France
| | - Sarah K Brode
- Department of Medicine, Division of Respirology, University of Toronto, West Park Healthcare Centre, University Health Network, and Sinai Health System, Toronto, ON, Canada
| | - James C M Brust
- Division of General Internal Medicine and Division of Infectious Diseases, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Ying Cai
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Bethesda, MD, USA
| | - Eric Caumes
- AP-HP, Service des Maladies Infectieuses et Tropicales, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Paris, France
| | - J Peter Cegielski
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rosella Centis
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Maugeri Care and Research Institute, Tradate, Italy
| | - Pei-Chun Chan
- Division of Chronic Infectious Diseases, Taiwan Centers for Disease Control, Taipei, Taiwan
| | - Edward D Chan
- Department of Medicine, University of Colorado Denver, Aurora, CO, USA; Department of Medicine, National Jewish Health, Denver, CO, USA; VA Medical Center, Denver, CO, USA
| | - Kwok-Chiu Chang
- Department of Health, Tuberculosis and Chest Service, Centre for Health Protection, Hong Kong Special Administrative Region, China
| | - Macarthur Charles
- Centers for Disease Control and Prevention, Haiti Country Office, Port-au-Prince, Haiti
| | - Andra Cirule
- Centre of TB and Lung Diseases, Riga East University Hospital, Riga, Latvia
| | | | - Lia D'Ambrosio
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Maugeri Care and Research Institute, Tradate, Italy; Public Health Consulting Group, Lugano, Switzerland
| | - Gerard de Vries
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands; KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Department of Medicine & UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Aliasgar Esmail
- Centre for Lung Infection and Immunity, Department of Medicine & UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Jennifer Flood
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, CA, USA
| | - Gregory J Fox
- Sydney Medical School, University of Sydney, NSW, Australia
| | | | - Geisa Fregona
- University Federal of Espirito Santo, Vitória, Brazil
| | | | - Medea Gegia
- Global Tuberculosis Program, World Health Organization, Geneva, Switzerland
| | | | - Sue Gu
- Department of Medicine, University of Colorado Denver, Aurora, CO, USA
| | - Lorenzo Guglielmetti
- AP-HP, Laboratoire de Bactériologie-Hygiène, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Paris, France; Sorbonne Université, Centre d'Immunologie et des Maladies Infectieuses (CIMI; INSERM U1135/UMRS CR7/CNRS ERL 8255), Bactériologie, Faculté de Médecine Sorbonne Université, Paris, France; Sanatorium, Centre Hospitalier de Bligny, Briis-sous-Forges, France
| | - Timothy H Holtz
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Leah Jarlsberg
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
| | - Russell R Kempker
- Emory University School of Medicine, Division of Infectious Diseases, Atlanta, GA, USA
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Faiz Ahmad Khan
- Montreal Chest Institute, McGill University Health Center Research Institute, McGill University, Montreal, QC, Canada
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Serena P Koenig
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Won-Jung Koh
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Afranio Kritski
- Academic Tuberculosis Program, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Liga Kuksa
- Department of MDR TB, Riga East University Hospital, Riga, Latvia
| | - Charlotte L Kvasnovsky
- Division of Pediatric Surgery, Cohen Children's Medical Center, Hofstra Northwell School of Medicine, New Hyde Park, NY, USA
| | - Nakwon Kwak
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Zhiyi Lan
- Montreal Chest Institute, McGill University Health Center Research Institute, McGill University, Montreal, QC, Canada
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Germany; German Center for Infection Research, Clinical Tuberculosis Unit, Borstel, Germany; International Health/Infectious Diseases, University of Luebeck, Luebeck, Germany; Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Myungsun Lee
- Clinical Research Section, International Tuberculosis Research Centre, Seoul, South Korea
| | - Vaira Leimane
- Centre of TB and Lung Diseases, Riga East University Hospital, Riga, Latvia
| | - Chi-Chiu Leung
- Department of Health, Tuberculosis and Chest Service, Centre for Health Protection, Hong Kong Special Administrative Region, China
| | - Eric Chung-Ching Leung
- Department of Health, Tuberculosis and Chest Service, Centre for Health Protection, Hong Kong Special Administrative Region, China
| | - Pei Zhi Li
- Montreal Chest Institute, McGill University Health Center Research Institute, McGill University, Montreal, QC, Canada
| | - Phil Lowenthal
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, CA, USA
| | | | - Suzanne M Marks
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sundari Mase
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA; Regional WHO Office, New Delhi, India
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Giovanni B Migliori
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Maugeri Care and Research Institute, Tradate, Italy
| | - Vladimir Milanov
- Medical Faculty, Medical University-Sofia, University Hospital for Respiratory Diseases "St. Sofia", Sofia, Bulgaria
| | - Ann C Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Carole D Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Erika Mohr
- Médecins Sans Frontières, Khayelitsha, South Africa
| | - Ignacio Monedero
- TB-HIV Department, International Union against Tuberculosis and Lung Diseases, Paris, France
| | - Payam Nahid
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
| | - Norbert Ndjeka
- National TB Programme, South African National Department of Health, Pretoria, South Africa
| | - Max R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Nesri Padayatchi
- CAPRISA, MRC TB-HIV Treatment and Pathogenesis Research Unit, Durban, South Africa
| | - Domingo Palmero
- Pulmonology Division, Municipal Hospital F J Munĩz, Buenos Aires, Argentina
| | - Jean William Pape
- Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti; Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Laura J Podewils
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ian Reynolds
- Department of Medicine, University of Colorado Denver, Aurora, CO, USA
| | - Vija Riekstina
- Centre of TB and Lung Diseases, Riga East University Hospital, Riga, Latvia
| | - Jérôme Robert
- AP-HP, Laboratoire de Bactériologie-Hygiène, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Paris, France; Sorbonne Université, Centre d'Immunologie et des Maladies Infectieuses (CIMI; INSERM U1135/UMRS CR7/CNRS ERL 8255), Bactériologie, Faculté de Médecine Sorbonne Université, Paris, France
| | | | - Barbara Seaworth
- Heartland National TB Center, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | | | - Kathryn Schnippel
- Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tae Sun Shim
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Seoul, South Korea
| | - Rupak Singla
- National Institute of Tuberculosis & Respiratory Diseases, New Delhi, India
| | - Sarah E Smith
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Giovanni Sotgiu
- Department of Medical, Surgical and Experimental Sciences, Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
| | | | - Payam Tabarsi
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Simon Tiberi
- Royal London Hospital, Barts Health NHS Trust, London, UK; Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anete Trajman
- Social Medicine Institute, Epidemiology Department, State University of Rio de Janeiro, Rio de Janeiro, Brazil; Montreal Chest Institute, McGill University Health Center Research Institute, McGill University, Montreal, QC, Canada; Academic Tuberculosis Program, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lisa Trieu
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, NY, USA
| | | | - Tjip S van der Werf
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands; Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Nicolas Veziris
- AP-HP, Laboratoire de Bactériologie-Hygiène, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Paris, France; Sorbonne Université, Centre d'Immunologie et des Maladies Infectieuses (CIMI; INSERM U1135/UMRS CR7/CNRS ERL 8255), Bactériologie, Faculté de Médecine Sorbonne Université, Paris, France
| | - Piret Viiklepp
- Estonian Tuberculosis Registry, National Institute for Health Development, Tallinn, Estonia
| | - Stalz Charles Vilbrun
- Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Kathleen Walsh
- Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Janice Westenhouse
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, CA, USA
| | - Wing-Wai Yew
- Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jae-Joon Yim
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Matteo Zignol
- Global Tuberculosis Program, World Health Organization, Geneva, Switzerland
| | - Dick Menzies
- Montreal Chest Institute, McGill University Health Center Research Institute, McGill University, Montreal, QC, Canada.
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Risk factors for mortality among adults registered on the routine drug resistant tuberculosis reporting database in the Eastern Cape Province, South Africa, 2011 to 2013. PLoS One 2018; 13:e0202469. [PMID: 30133504 PMCID: PMC6104983 DOI: 10.1371/journal.pone.0202469] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/04/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION South Africa is among countries with the highest burden of drug resistant tuberculosis (DR-TB). The Eastern Cape Province reported the highest MDR-TB mortality rates in South Africa for the 2010 treatment cohorts. This study aimed to determine risk factors for mortality among adult patients registered for DR-TB treatment in the province. METHODS We conducted a retrospective cohort study of adult patients treated for laboratory confirmed DR-TB between January 2011 and December 2013. Demographic and clinical characteristics of the patients were obtained from a web-based electronic database of patients treated for DR-TB. We applied modified Poisson regression with robust standard errors to identify risk factors for DR-TB mortality. We also stratified the analyses into multi-drug resistant TB (MDR-TB) and extensively drug resistant (XDR-TB). RESULTS Among 3,729 patients that met the inclusion criteria, 39% (n = 1,445) died. Of the patients that died, 53% (n = 766) were male, 68% (n = 982) had MDR-TB, 72% (n = 1,038) were HIV co-infected, and median age was 37 years (Interquartile Range [IQR] 30-46). Patients were at higher risk of mortality during DR-TB treatment if they were HIV co-infected not on antiretroviral treatment (ART) (adjusted incidence risk ratio [aIRR] 3.3, 95% confidence interval [CI] 2.9-3.8), were 60 years or older (aIRR 1.7, 95%CI 1.5-2.0), had a diagnosis of XDR-TB (aIRR 1.6, 95%CI 1.5-1.7), or had been hospitalised at treatment start (aIRR 1.7, 95%CI 1.5-1.8). Among MDR-TB patients, risk of mortality was higher if patients were HIV co-infected not on ART (aIRR 3.9, 95%CI 3.3-4.6), were 60 years or older (aIRR 1.9, 95%CI 1.6-2.3), or had been hospitalised at start of MDR-TB treatment (aIRR 1.7, 95%CI 1.5-1.9). Among XDR-TB patients, risk of mortality was higher in patients who were HIV co-infected not on ART (aIRR 1.8, 95%CI 1.5-2.2), or had been hospitalised at the start of XDR-TB treatment (aIRR 1.5, 95%CI 1.3-1.8). CONCLUSION HIV co-infected not on ART, older age, XDR-TB and hospital admission for DR-TB treatment were independent risk factors for DR-TB mortality. Integration of TB and HIV services, with focus on voluntary HIV testing and counselling of DR-TB patients with unknown HIV status, and provision of ART for all co-infected patients may reduce DR-TB mortality in the Eastern Cape.
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Effect of bedaquiline on mortality in South African patients with drug-resistant tuberculosis: a retrospective cohort study. THE LANCET RESPIRATORY MEDICINE 2018; 6:699-706. [PMID: 30001994 DOI: 10.1016/s2213-2600(18)30235-2] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Addition of bedaquiline to treatment for multidrug-resistant tuberculosis was associated with an increased risk of death in a phase 2b clinical trial, resulting in caution from WHO. Following a compassionate access programme and local regulatory approval, the South African National Tuberculosis Programme began widespread use of bedaquiline in March, 2015, especially among patients with extensively drug resistant tuberculosis for whom no other effective treatment options were available. We aimed to compare mortality in patients on standard regimens with that of patients on regimens including bedaquiline. METHODS In this retrospective cohort study, we analysed patient data from the South African rifampicin-resistant tuberculosis case register (EDRweb), and identified additional mortality using the national vital statistics register. We excluded patients who started treatment before July 1, 2014, or after March 31, 2016; patients younger than 15 years or older than 75 years; patients without documented rifampicin resistance, and patients with pre-extensively drug-resistant tuberculosis (multidrug-resistant tuberculosis with further resistance to a second-line injectable or fluoroquinolone). We compared all-cause mortality between patients who received bedaquiline in treatment regimens and those who did not. Patients who did not receive bedaquiline had kanamycin or capreomycin and moxifloxacin as core medicines in their regimen. We estimated hazard ratios for mortality separately for multidrug-resistant or rifampicin-resistant tuberculosis and extensively drug-resistant tuberculosis and adjusted using propensity score quintile strata for the potential confounders of sex, age, HIV and antiretroviral therapy status, history of prior tuberculosis, valid identification number, and year and province of treatment. FINDINGS 24 014 tuberculosis cases were registered in the EDRweb between July 1, 2014, and March 31, 2016. Of these, 19 617 patients initiated treatment and met our analysis eligibility criteria. A bedaquiline-containing regimen was given to 743 (4·0%) of 18 542 patients with multidrug-resistant or rifampicin-resistant tuberculosis and 273 (25·4%) of 1075 patients with extensively drug-resistant tuberculosis. Among 1016 patients who received bedaquiline, 128 deaths (12·6%) were reported, and there were 4612 deaths (24·8%) among 18 601 patients on the standard regimens. Bedaquiline was associated with a reduction in the risk of all-cause mortality for patients with multidrug-resistant or rifampicin-resistant tuberculosis (hazard ratio [HR] 0·35, 95% CI 0·28-0·46) and extensively drug-resistant tuberculosis (0·26, 0·18-0·38) compared with standard regimens. INTERPRETATION Our retrospective cohort analysis of routinely reported data in the context of high HIV and extensively drug-resistant tuberculosis prevalence showed that bedaquiline-based treatment regimens were associated with a large reduction in mortality in patients with drug-resistant tuberculosis, compared with the standard regimen. FUNDING None.
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46
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Chang KC, Nuermberger E, Sotgiu G, Leung CC. New drugs and regimens for tuberculosis. Respirology 2018; 23:978-990. [PMID: 29917287 DOI: 10.1111/resp.13345] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 04/17/2018] [Accepted: 05/24/2018] [Indexed: 11/30/2022]
Abstract
Since standardized rifampin-based first-line regimens and fluoroquinolone-based second-line regimens were used to treat tuberculosis (TB), unfortunately without timely modification according to the drug resistance profile, TB and drug-resistant disease are still important public health threats worldwide. Although the last decade has witnessed advances in rapid diagnostic tools and use of repurposed and novel drugs for better managing drug-resistant TB, we need an appropriate TB control strategy and a well-functioning health infrastructure to ensure optimal operational use of rapid tests, judicious use of effective treatment regimens that can be rapidly tailored according to the drug resistance profile and timely management of risk factors and co-morbidities that promote infection and its progression to disease. We searched the published literature to discuss (i) standardized versus individualized therapies, including the choice between a single one-size-fit-all regimen versus different options with different key drugs determined mainly by rapid drug susceptibility testing, (ii) alternative regimens for managing drug-susceptible TB, (iii) evidence for using the World Health Organization (WHO) longer and shorter regimens for multidrug-resistant TB and (iv) evidence for using repurposed and novel drugs. We hope an easily applicable combination of biomarkers that accurately predict individual treatment outcome will soon be available to ultimately guide individualized therapy.
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Affiliation(s)
- Kwok-Chiu Chang
- Department of Health, Tuberculosis and Chest Service, Hong Kong, China
| | - Eric Nuermberger
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Chi-Chiu Leung
- Department of Health, Tuberculosis and Chest Service, Hong Kong, China
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Mohr E, Hughes J, Reuter A, Trivino Duran L, Ferlazzo G, Daniels J, De Azevedo V, Kock Y, Steele SJ, Shroufi A, Ade S, Alikhanova N, Benedetti G, Edwards J, Cox H, Furin J, Isaakidis P. Delamanid for rifampicin-resistant tuberculosis: a retrospective study from South Africa. Eur Respir J 2018; 51:13993003.00017-2018. [PMID: 29724920 PMCID: PMC6485275 DOI: 10.1183/13993003.00017-2018] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/23/2018] [Indexed: 11/05/2022]
Abstract
Experience with delamanid (Dlm) is limited, particularly among HIV-positive individuals. We describe early efficacy and safety data from a programmatic setting in South Africa.This was a retrospective cohort study of patients receiving Dlm-containing treatment regimens between November 2015 and August 2017. We report 12-month interim outcomes, sputum culture conversion (SCC) by months 2 and 6, serious adverse events (SAEs) and QT intervals corrected using the Frederica formula (QTcF).Overall, 103 patients were initiated on Dlm; 79 (77%) were HIV positive. The main indication for Dlm was intolerance to second-line anti-tuberculosis (TB) drugs (n=58, 56%). There were 12 months of follow-up for 46 patients; 28 (61%) had a favourable outcome (cure, treatment completion or culture negativity). Positive cultures were found for 57 patients at Dlm initiation; 16 out of 31 (52%) had SCC within 2 months and 25 out of 31 (81%) within 6 months. There were 67 SAEs reported in 29 patients (28%). There were four instances of QTcF prolongation >500 ms in two patients (2%), leading to permanent discontinuation in one case; however, no cardiac arrhythmias occurred.This large cohort of difficult-to-treat patients receiving Dlm for rifampicin-resistant TB treatment in a programmatic setting with high HIV prevalence had favourable early treatment response and tolerated treatment well. Dlm should remain available, particularly for those who cannot be treated with conventional regimens or with limited treatment options.
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Affiliation(s)
- Erika Mohr
- Médecins Sans Frontières, Operational Centre Brussels (OCB), Khayelitsha Project, Cape Town, South Africa
| | - Jennifer Hughes
- Médecins Sans Frontières, Operational Centre Brussels (OCB), Khayelitsha Project, Cape Town, South Africa
| | - Anja Reuter
- Médecins Sans Frontières, Operational Centre Brussels (OCB), Khayelitsha Project, Cape Town, South Africa
| | - Laura Trivino Duran
- Médecins Sans Frontières, Operational Centre Brussels (OCB), Khayelitsha Project, Cape Town, South Africa
| | - Gabriella Ferlazzo
- Médecins Sans Frontières, South African Medical Unit (SAMU), Cape Town, South Africa
| | - Johnny Daniels
- Médecins Sans Frontières, Operational Centre Brussels (OCB), Khayelitsha Project, Cape Town, South Africa
| | | | - Yulene Kock
- Provincial Government of the Western Cape Dept of Health, Cape Town, South Africa
| | - Sarah Jane Steele
- Médecins Sans Frontières, Operational Centre Brussels (OCB), Cape Town Coordination, Cape Town, South Africa
| | - Amir Shroufi
- Médecins Sans Frontières, Operational Centre Brussels (OCB), Cape Town Coordination, Cape Town, South Africa
| | - Serge Ade
- Faculty of Medicine, University of Parakou, Parakou, Benin
| | | | - Guido Benedetti
- Médecins Sans Frontières, Medical Dept (Operational Research), Operational Centre Brussels (OCB), Luxembourg City, Luxembourg
| | - Jeffrey Edwards
- Médecins Sans Frontières, Medical Dept (Operational Research), Operational Centre Brussels (OCB), Luxembourg City, Luxembourg.,Dept of Global Health, University of Washington, Seattle, WA, USA
| | - Helen Cox
- Division of Medical Microbiology and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Furin
- Dept of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Petros Isaakidis
- Médecins Sans Frontières, South African Medical Unit (SAMU), Cape Town, South Africa
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48
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Olayanju O, Limberis J, Esmail A, Oelofse S, Gina P, Pietersen E, Fadul M, Warren R, Dheda K. Long-term bedaquiline-related treatment outcomes in patients with extensively drug-resistant tuberculosis from South Africa. Eur Respir J 2018; 51:13993003.00544-2018. [PMID: 29700106 DOI: 10.1183/13993003.00544-2018] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/04/2018] [Indexed: 01/08/2023]
Abstract
Optimal treatment regimens for patients with extensively drug-resistant tuberculosis (XDR-TB) remain unclear. Long-term prospective outcome data comparing XDR-TB regimens with and without bedaquiline from an endemic setting are lacking.We prospectively followed-up 272 South African patients (49.3% HIV-infected; median CD4 count 169 cells·µL-1) with newly diagnosed XDR-TB between 2008 and 2017. Outcomes were compared between those who had not received bedaquiline (pre-2013; n=204) and those who had (post-2013; n=68; 80.9% received linezolid in addition).The 24-month favourable outcome rate was substantially better in the bedaquiline versus the non-bedaquiline group (66.2% (45 out of 68) versus 13.2% (27 out of 204); p<0.001). In addition, the bedaquiline group exhibited reduced 24-month rates of treatment failure (5.9% versus 26.0%; p<0.001) and default (1.5% versus 15.2%; p<0.001). However, linezolid was withdrawn in 32.7% (18 out of 55) of patients in the bedaquiline group because of adverse events. Admission weight >50 kg, an increasing number of anti-TB drugs and bedaquiline were independent predictors of survival (the bedaquiline survival effect remained significant in HIV-infected persons, irrespective of CD4 count).XDR-TB patients receiving a backbone of bedaquiline and linezolid had substantially better favourable outcomes compared to those not using these drugs. These data inform the selection of XDR-TB treatment regimens and roll-out of newer drugs in TB-endemic countries.
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Affiliation(s)
- Olatunde Olayanju
- Lung Infection and Immunity Unit, Division of Pulmonology, Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jason Limberis
- Lung Infection and Immunity Unit, Division of Pulmonology, Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Division of Pulmonology, Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Suzette Oelofse
- Lung Infection and Immunity Unit, Division of Pulmonology, Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phindile Gina
- Lung Infection and Immunity Unit, Division of Pulmonology, Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Elize Pietersen
- Lung Infection and Immunity Unit, Division of Pulmonology, Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mohammed Fadul
- Lung Infection and Immunity Unit, Division of Pulmonology, Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rob Warren
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, US/SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Depts of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology, Dept of Medicine, University of Cape Town, Cape Town, South Africa
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49
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Esmail A, Sabur NF, Okpechi I, Dheda K. Management of drug-resistant tuberculosis in special sub-populations including those with HIV co-infection, pregnancy, diabetes, organ-specific dysfunction, and in the critically ill. J Thorac Dis 2018; 10:3102-3118. [PMID: 29997980 DOI: 10.21037/jtd.2018.05.11] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tuberculosis remains a major problem globally, and is the leading cause of death from an infectious agent. Drug-resistant tuberculosis threatens to marginalise the substantial gains that have recently been made in the fight against tuberculosis. Drug-resistant TB has significant associated morbidity and a high mortality, with only half of all multidrug-resistant TB patients achieving a successful treatment outcome. Patients with drug-resistant TB in resource-poor settings are now gaining access to newer and repurposed anti-tuberculosis drugs such as bedaquiline, delamanid and linezolid. However, with ever increasing rates of co-morbidity, there is little guidance on how to manage complex patients with drug-resistant TB. We address that knowledge gap, and outline principles underpinning the management of drug-resistant TB in special situations including HIV co-infection, pregnancy, renal disease, liver disease, diabetes, and in the critically ill.
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Affiliation(s)
- Aliasgar Esmail
- Lung Infection and Immunity Unit, Division of Pulmonology and University of Cape Town Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Natasha F Sabur
- Lung Infection and Immunity Unit, Division of Pulmonology and University of Cape Town Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Division of Respirology, Department of Medicine, St. Michael's Hospital and West Park Healthcare Centre, Toronto, Canada
| | - Ikechi Okpechi
- Division of Nephrology, Department of Medicine University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and University of Cape Town Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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50
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Schnippel K, Firnhaber C, Berhanu R, Page-Shipp L, Sinanovic E. Adverse drug reactions during drug-resistant TB treatment in high HIV prevalence settings: a systematic review and meta-analysis. J Antimicrob Chemother 2018; 72:1871-1879. [PMID: 28419314 DOI: 10.1093/jac/dkx107] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 03/13/2017] [Indexed: 01/16/2023] Open
Abstract
Objectives To estimate the prevalence of adverse drug reactions or events (ADR) during drug-resistant TB (DR-TB) treatment in the context of settings with high HIV prevalence (at least 20% of patients). Methods We conducted a systematic review and meta-analysis of articles in PubMed and Scopus. Pooled proportions of patients experiencing adverse events and relative risk with 95% CI were calculated. Results The search yielded 24 studies, all observational cohorts. Ten reported on the number of patients experiencing ADR and were included in the meta-analysis representing 2776 study participants of whom 1943 were known to be HIV infected (70.0%). An average of 83% (95% CI: 82%-84%) of patients experienced one or more ADR. Among the seven articles ( n = 664 study participants) with information on occurrence of severe ADR, 24% (95% CI: 21%-27%) of patients experienced at least one severe ADR during drug-resistant TB treatment. Sixteen of the 24 studies analysed the relative risk of ADR by HIV infection, nine of which found no statistically significant association between HIV infection and occurrence of drug-related ADR. There was insufficient information to disaggregate risk by concomitant treatment with HIV antiretrovirals or by immunosuppression (CD4 count). Conclusions No randomized clinical trials were found for WHO-recommended treatment of drug-resistant TB treatment where at least 20% of the cohort was coinfected with HIV. Nearly all patients (83%) experience ADR during DR-TB treatment. While no significant association between ADR and HIV coinfection was found, further research is needed to determine whether concomitant antiretrovirals or immunosuppression increases the risks for HIV-infected patients.
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Affiliation(s)
- Kathryn Schnippel
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Right to Care, Johannesburg, South Africa
| | - Cynthia Firnhaber
- Right to Care, Johannesburg, South Africa.,Clinical HIV Research Unit, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rebecca Berhanu
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Health Economics & Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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