Higher-dose rifampin for the treatment of pulmonary tuberculosis: a systematic review

OBJECTIVE

To provide a descriptive synthesis of the evidence assessing the efficacy and safety of higher doses of rifampin (RMP) for the treatment of pulmonary tuberculosis (TB).

METHODS

Systematic review of randomized controlled trials that evaluate a range of RMP doses, including doses higher than standard (>10 mg/kg or >600 mg), used as part of combination drug therapies for pulmonary TB. Two reviewers applied inclusion criteria, assessed trial quality and extracted data. Inclusion criteria were smear- or culture-confirmed pulmonary TB, and English and French language articles. Exclusion criteria were RMP monotherapy and smear-negative TB. Outcomes included were sputum culture conversion, treatment failure, recurrence and adverse events, including hepatotoxicity and flu-like syndrome.

RESULTS

Of 14 trials (4256 participants) identified, 12 were conducted before 1980. Four trials were considered high quality according to published guidelines. Study characteristics, including history of prior TB treatment, dose of RMP, duration of treatment, timing of introduction of intervention treatment, concomitant drugs, and duration of follow-up, varied, making synthesis of efficacy data challenging. Several trials suggested an advantage in terms of likelihood of culture conversion among patients receiving at least 900 mg RMP. However, an increased incidence of flu-like syndrome was seen when RMP doses of 900 mg and higher were given intermittently.

CONCLUSION

Historical trials suggest that higher than standard RMP dosing results in improved culture conversion rates. Phase 2 and 3 clinical trials evaluating higher doses of RMP and other rifamycins are needed to confirm efficacy and assure tolerability. Pharmacokinetic studies will be needed to inform the development of such trials.

[Lesions of the little finger in Dupuytren's disease]

One hundred and twenty six patients (148 hands) with Dupuytren's disease of the fifth finger were reviewed with an average follow-up of 5 years. Twenty-nine dermo-fasciectomies were performed on the palmar area of the fifth finger. The improvement in the MP joint was complete in all cases. A classification in to 4 grades according to the degree of pre- and postoperative retraction is proposed. The average improvement at the PIP joint was 50 degrees. 26 recurrences were observed. The recurrence rate was similar with or without a skin graft but the functional result was better with a digital graft, as recurrences were located away from the PIP joint.

Odontogenic sinus tracts

Odontogenic sinus tracts are the most common cause of a chronically draining, fixed, nodulocystic papule of the face and neck. Injury or disease of a tooth may result in a periapical abscess that subsequently dissects along the path of least resistance and erupts through the skin. If recognized early, the sinus tract usually resolves after appropriate endodontic therapy or extraction.