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Mutayoba BK, Ershova J, Lyamuya E, Hoelscher M, Heinrich N, Kilale AM, Range NS, Ngowi BJ, Ntinginya NE, Mfaume SM, Nkiligi E, Doulla B, Lyimo J, Kisonga R, Kingalu A, Lema Y, Kondo Z, Pletschette M. The second national anti-tuberculosis drug resistance survey in Tanzania, 2017-2018. Trop Med Int Health 2022; 27:891-901. [PMID: 36089572 PMCID: PMC9826299 DOI: 10.1111/tmi.13814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine the levels and patterns of resistance to first- and second-line anti-tuberculosis (TB) drugs among new and previously treated sputum smear positive pulmonary TB (PTB) patients. METHODS We conducted a nationally representative cross-sectional facility-based survey in June 2017-July 2018 involving 45 clusters selected based on probability proportional to size. The survey aimed to determine the prevalence of anti-TB drug resistance and associated risk factors among smear positive PTB patients in Tanzania. Sputum samples were examined using smear microscopy, Xpert MTB/RIF, culture and drug susceptibility testing (DST). Logistic regression was used to account for missing data and sampling design effects on the estimates and their standard errors. RESULTS We enrolled 1557 TB patients, including 1408 (90.4%) newly diagnosed and 149 (9.6%) previously treated patients. The prevalence of multidrug-resistant TB (MDR-TB) was 0.85% [95% confidence interval (CI): 0.4-1.3] among new cases and 4.6% (95% CI: 1.1-8.2) among previously treated cases. The prevalence of Mycobacterium tuberculosis strains resistant to any of the four first-line anti-TB drugs (isoniazid, rifampicin, streptomycin and ethambutol) was 1.7% among new TB patients and 6.5% among those previously treated. Drug resistance to all first-line drugs was similar (0.1%) in new and previously treated patients. None of the isolates displayed poly-resistance or extensively drug-resistant TB (XDR-TB). The only risk factor for MDR-TB was history of previous TB treatment (odds ratio = 5.7, 95% CI: 1.9-17.2). CONCLUSION The burden of MDR-TB in the country was relatively low with no evidence of XDR-TB. Given the overall small number of MDR-TB cases in this survey, it will be beneficial focusing efforts on intensified case detection including universal DST.
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Affiliation(s)
- Beatrice Kemilembe Mutayoba
- Department of Preventive ServicesMinistry of Health National AIDS Control ProgramDodomaTanzania,Department of Infectious Diseases and Tropical MedicineMedical Center of the University of MunichMunichGermany
| | - Julia Ershova
- Division of Global HIV and TB, Global TB BranchUS Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Eligius Lyamuya
- Department of Microbiology and ImmunologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Michael Hoelscher
- Department of Infectious Diseases and Tropical MedicineMedical Center of the University of MunichMunichGermany
| | - Norbert Heinrich
- Department of Infectious Diseases and Tropical MedicineMedical Center of the University of MunichMunichGermany
| | - Andrew Martin Kilale
- Muhimbili Medical Research CentreNational Institute for Medical ResearchDar es SalaamTanzania
| | - Nyagosya Segere Range
- Muhimbili Medical Research CentreNational Institute for Medical ResearchDar es SalaamTanzania
| | - Benard James Ngowi
- Mbeya College of Health and Allied SciencesUniversity of Dar es SalaamMbeyaTanzania
| | | | - Saidi Mwinjuma Mfaume
- Muhimbili Medical Research CentreNational Institute for Medical ResearchDar es SalaamTanzania
| | - Emmanuel Nkiligi
- National Tuberculosis and Leprosy Program, Department of Preventive ServicesMinistry of HealthDodomaTanzania
| | - Basra Doulla
- National Tuberculosis and Leprosy ProgramCentral Tuberculosis Reference LaboratoryDar es SalaamTanzania
| | - Johnson Lyimo
- National Tuberculosis and Leprosy Program, Department of Preventive ServicesMinistry of HealthDodomaTanzania
| | - Riziki Kisonga
- Kibong'oto Infectious Diseases HospitalKilimanjaroTanzania
| | - Amri Kingalu
- National Tuberculosis and Leprosy Program, Department of Preventive ServicesMinistry of HealthDodomaTanzania
| | - Yakobo Lema
- Muhimbili Medical Research CentreNational Institute for Medical ResearchDar es SalaamTanzania
| | - Zuwena Kondo
- National Tuberculosis and Leprosy Program, Department of Preventive ServicesMinistry of HealthDodomaTanzania
| | - Michel Pletschette
- Department of Infectious Diseases and Tropical MedicineMedical Center of the University of MunichMunichGermany
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Song WM, Guo J, Xu TT, Li SJ, Liu JY, Tao NN, Liu Y, Zhang QY, Liu SQ, An QQ, Li YF, Yu CB, Dong JH, Li HC. Association between body mass index and newly diagnosed drug-resistant pulmonary tuberculosis in Shandong, China from 2004 to 2019. BMC Pulm Med 2021; 21:399. [PMID: 34872558 PMCID: PMC8647447 DOI: 10.1186/s12890-021-01774-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 12/01/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Drug-resistant tuberculosis (DR-TB), obesity, and malnutrition are growing public health problems in the world. However, little has discussed the impact of different BMI status on the emergence of TB drug resistance. We aimed to explore the drug-resistant profiles of DR-TB and its clinical predictors among underweight, overweight or obesity population. METHODS 8957 newly diagnosed TB cases with drug susceptibility results and BMI data in Shandong China, from 2004 to 2019 were enrolled. Multivariable and univariable logistic regression models were applied to investigate the impact of BMI on different drug-resistance. Clinical predicators and drug-resistant profiles of DR-TB among obesity, underweight, normal TB group were also described. RESULTS Among 8957 TB cases, 6417 (71.64%) were normal weight, 2121 (23.68%) were underweight, 373 (4.16%) were overweight, and 46 (0.51%) were obese. The proportion of drug resistance and co-morbidity among normal weight, underweight, overweight, obese TB groups were 18.86%/18.25%/20.38%/23.91% (DR-TB), 11.19%/11.74%/9.65%/17.39% (mono-resistant tuberculosis, MR-TB), 3.41%/3.06%/5.36%/0.00% (multidrug resistant tuberculosis, MDR-TB), 4.21%/3.39%/5.36%/6.52% (polydrug resistant tuberculosis, PDR-TB), 10.57%/8.44%/19.57%/23.91% (co-morbidity), respectively. Compared with normal weight group, underweight were associated with lower risk of streptomycin-related resistance (OR 0.844, 95% CI 0.726-0.982), but contributed to a higher risk of MR-TB (isoniazid) (odds ratio (OR) 1.347, 95% CI 1.049-1.730; adjusted OR (aOR) 1.31, 95% CI 1.017-1.686), P < 0.05. In addition, overweight were positively associated with MDR-TB (OR 1.603, 95% CI 1.002-2.566; aOR 1.639, 95% CI 1.02-2.633), isoniazid + rifampicin + streptomycin resistance (OR 1.948, 95% confidence interval (CI): 1.061-3.577; aOR 2.113, 95% CI 1.141-3.912), Any isoniazid + streptomycin resistance (OR 1.472, 95% CI 1.013-2.14; aOR 1.483, 95% CI 1.017-2.164), P < 0.05. CONCLUSIONS The higher risk of MDR-TB, isoniazid + rifampicin + streptomycin resistance, Any isoniazid + streptomycin resistance, and co-morbidity among overweight population implies that routine screening for drug sensitivity and more attention on co-morbidity among overweight TB cases may be necessary. In addition, underweight TB cases have a higher risk of isoniazid resistance. Our study suggests that an in-depth study of the interaction between host metabolic activity and infection of DR-TB may contribute more to novel treatment options or preventive measures, and accelerate the implementation of the STOP TB strategy.
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Affiliation(s)
- Wan-Mei Song
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, People's Republic of China.,Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, People's Republic of China
| | - Jing Guo
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, People's Republic of China.,School of Medicine and Life Sciences, Shandong First Medical University and Shandong Academy of Medical Sciences, Taian, 271016, Shandong, People's Republic of China.,Department of Emergency, The Fifth People's Hospital of Jinan, Jinan, 250031, Shandong, People's Republic of China
| | - Ting-Ting Xu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, People's Republic of China.,School of Medicine and Life Sciences, Shandong First Medical University and Shandong Academy of Medical Sciences, Taian, 271016, Shandong, People's Republic of China
| | - Shi-Jin Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, People's Republic of China.,Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, People's Republic of China
| | - Jin-Yue Liu
- Department of Intensive Care Unit, Shandong Provincial Third Hospital, Jinan, 100191, Shandong, People's Republic of China
| | - Ning-Ning Tao
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, Beijing, 100730, People's Republic of China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, People's Republic of China
| | - Yao Liu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, People's Republic of China
| | - Qian-Yun Zhang
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, People's Republic of China.,Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, People's Republic of China
| | - Si-Qi Liu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, People's Republic of China.,Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, People's Republic of China
| | - Qi-Qi An
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, People's Republic of China.,Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, People's Republic of China
| | - Yi-Fan Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, People's Republic of China
| | - Chun-Bao Yu
- Katharine Hsu International Research Center of Human Infectious Diseases, Shandong Provincial Chest Hospital, Jinan, 250013, Shandong, People's Republic of China
| | - Ji-Hua Dong
- Department of Respiratory Medicine, Heze Mudan People's Hospital, Heze, 274000, Shandong, People's Republic of China.
| | - Huai-Chen Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, People's Republic of China. .,College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, 250355, Shandong, People's Republic of China.
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3
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Ateba-Ngoa U, Edoa JR, Adegbite BR, Rossatanga EG, Madiou D, Mfoumbi A, Mevyann C, Achimi Agbo P, Mahoumbou J, Gould S, Lell B, Adegnika AA, Köhler C, Kremsner PG, Massinga-Loembe M, Alabi A, Grobusch MP. Implementation of multidrug-resistant tuberculosis (MDR-TB) treatment in Gabon: lessons learnt from the field. Infection 2019; 47:811-816. [PMID: 31073710 DOI: 10.1007/s15010-019-01314-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 04/30/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Since May 2016, WHO recommended a 9-12 month short-treatment regimen for multidrug-resistant tuberculosis (MDR-TB) treatment known as the 'Bangladesh Regimen'. However, limited data exist on the appropriateness thereof, and its implementation in low- and middle-income countries (LMIC). We report here on the pilot phase of the evaluation of the Bangladesh regimen in Gabon, prior to its endorsement by the WHO. METHODS This ongoing observational study started in September 2015. Intensive training of hospital health workers as well as community information and education were conducted. GeneXpert-confirmed MDR-TB patients received the second-line anti-tuberculosis drugs (4KmMfxPtoHCfzEZ/5MfxCfzEZ). Sputum smears and cultures were done monthly. Adverse events were monitored daily. RESULTS Eleven patients have been treated for MDR-TB piloting the short regimen. All were HIV-negative and presented in poor health with extensive pulmonary lesions. The overall sputum culture conversion rate was 64% after 4 months of treatment. Three patients developed marked hearing loss; one a transient cutaneous rash. Of 11 patients in our continuous care, 7 (63.6%) significantly improved clinically and bacteriologically. One (9.1%) patient experienced a treatment failure, two (18.2%) died, and one (9.1%) was lost to follow up. CONCLUSIONS Our pioneering data on systematic MDR-TB treatment in Gabon, with currently almost total absence of resistance against the second-line drugs, demonstrate that a 9-month regimen has the capacity to facilitate early culture negativity and sustained clinical improvement. Close adverse events monitoring and continuous care are vital to success.
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Affiliation(s)
- U Ateba-Ngoa
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
- Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany
| | - J R Edoa
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
- Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany
| | - B R Adegbite
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
- Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany
| | - E G Rossatanga
- Centre Hospitalier Régional Georges Rawiri de Lambaréné, Lambarene, Gabon
| | - D Madiou
- Centre Hospitalier Régional Georges Rawiri de Lambaréné, Lambarene, Gabon
| | - A Mfoumbi
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
| | - C Mevyann
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
| | - P Achimi Agbo
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
| | - J Mahoumbou
- Programme National de Lutte contre la Tuberculose, Ministry of Health, Libreville, Gabon
| | - S Gould
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
| | - B Lell
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
- Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany
| | - A A Adegnika
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
- Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany
| | - C Köhler
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
- Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany
| | - P G Kremsner
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
- Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany
| | - M Massinga-Loembe
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
- Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany
| | - A Alabi
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon
- Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany
| | - M P Grobusch
- Centre des Recherches Médicales de Lambaréné, Lambarene, Gabon.
- Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany.
- Department of Infectious Diseases, Center of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.
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4
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Faleye A, Adegoke A, Ramluckan K, Bux F, Stenström TA. Antibiotic Residue in the Aquatic Environment: Status in Africa. OPEN CHEM 2018. [DOI: 10.1515/chem-2018-0099] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
AbstractInformation on the presence of antibiotics is sparse for all types of water in Africa, including groundwater, surface water, effluent of wastewater treatment plants (WWTPs) and municipal potable water. With the relatively high sales of different antibiotics to treat infectious diseases in the human population of Africa, the residual of the antibiotics is bound to be released through excretion via urine or fecal matter in parallel to the high sales. This article reviews the published analysis on the occurrence of antibiotics in the environment particularly in the aquatic environment in some countries in Africa. In general, sulfamethoxazole was the most commonly detected in Africa surface water (with eight reports from four countries) at a concentration range of 0.00027 – 39 μgL-1. Wastewater analysis is believed to give an early warning for preventing epidemics. Thus, we discuss the associated level of antibiotic resistance to some prevalent diseases in Africa whose aetiological agents can develop antibiotic resistance due to exposure to antibiotic residue in water. This is important because of rising population of immuno-deficient African residents ravaged by HIV/AIDS, poor nutrition and less efficient sanitation systems.
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Affiliation(s)
- A.C. Faleye
- Institute for Water and Wastewater Technology, Durban University of Technology, Durban, South Africa
- Department of Chemistry, Faculty of Applied Sciences, Durban University of Technology, Durban, South Africa
| | - A.A. Adegoke
- Institute for Water and Wastewater Technology, Durban University of Technology, Durban, South Africa
| | - K. Ramluckan
- Department of Chemistry, Faculty of Applied Sciences, Durban University of Technology, Durban, South Africa
| | - Faizal Bux
- Institute for Water and Wastewater Technology, Durban University of Technology, Durban, South Africa
| | - T. A. Stenström
- Institute for Water and Wastewater Technology, Durban University of Technology, Durban, South Africa
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5
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Lange C, Chesov D, Heyckendorf J, Leung CC, Udwadia Z, Dheda K. Drug-resistant tuberculosis: An update on disease burden, diagnosis and treatment. Respirology 2018; 23:656-673. [PMID: 29641838 DOI: 10.1111/resp.13304] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 01/02/2023]
Abstract
The emergence of antimicrobial resistance against Mycobacterium tuberculosis, the leading cause of mortality due to a single microbial pathogen worldwide, represents a growing threat to public health and economic growth. The global burden of multidrug-resistant tuberculosis (MDR-TB) has recently increased by an annual rate of more than 20%. According to the World Health Organization approximately only half of all patients treated for MDR-TB achieved a successful outcome. For many years, patients with drug-resistant tuberculosis (TB) have received standardized treatment regimens, thereby accelerating the development of MDR-TB through drug-specific resistance amplification. Comprehensive drug susceptibility testing (phenotypic and/or genotypic) is necessary to inform physicians about the best drugs to treat individual patients with tailor-made treatment regimens. Phenotypic drug resistance can now often, but with variable sensitivity, be predicted by molecular drug susceptibility testing based on whole genome sequencing, which in the future could become an affordable method for the guidance of treatment decisions, especially in high-burden/resource-limited settings. More recently, MDR-TB treatment outcomes have dramatically improved with the use of bedaquiline-based regimens. Ongoing clinical trials with novel and repurposed drugs will potentially further improve cure-rates, and may substantially decrease the duration of MDR-TB treatment necessary to achieve relapse-free cure.
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Affiliation(s)
- Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,German Center for Infection Research (DZIF), TTU-TB, Borstel, Germany.,International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany.,Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Dumitru Chesov
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,Department of Pneumology and Allergology, State University of Medicine and Pharmacy "Nicolae Testemitanu", Chisinau, Republic of Moldova
| | - Jan Heyckendorf
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,German Center for Infection Research (DZIF), TTU-TB, Borstel, Germany.,International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - Chi C Leung
- Department of Health, Tuberculosis and Chest Service, Centre for Health Protection, Hong Kong, China
| | - Zarir Udwadia
- Department of Pulmonology, Hinduja Hospital and Research Centre, Mumbai, India
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
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6
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Byrne AL, Fox GJ, Marais BJ. Better than a pound of cure: preventing the development of multidrug-resistant tuberculosis. Future Microbiol 2018. [PMID: 29521120 DOI: 10.2217/fmb-2017-0236] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Diagnostic and treatment delays contribute to increased death and disability among the 490,000 adults and children who develop multidrug-resistant (MDR) tuberculosis every year. Since the treatment of MDR tuberculosis is complex, costly and often toxic, tuberculosis control programs should prioritize strategies to prevent drug-resistant tuberculosis. Opportunities to limit transmission and prevent disease progression in close contacts of MDR tuberculosis cases are often neglected. Effective MDR tuberculosis preventive strategies could minimize the costs for patients and healthcare systems. This review characterizes the biological basis for the development of MDR tuberculosis, outlines the evidence for strategies to reduce transmission and highlights programmatic approaches to the management of patients infected with drug-resistant strains of Mycobacterium tuberculosis.
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Affiliation(s)
- Anthony L Byrne
- St Vincent's Hospital, Heart Lung Clinic, Sydney, Australia.,Western Sydney Local Health District, Lung & Sleep Centre, Blacktown Hospital, Sydney, Australia.,Socios En Salud Sucursal Partners In Health, Lima, Peru
| | - Greg J Fox
- Central Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases & Biosecurity (MBI), University of Sydney, Sydney, Australia
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