Towards tailored regimens in the treatment of drug-resistant tuberculosis: a retrospective study in two Italian reference Centres

Background

The increased incidence of drug-resistant TB is a major challenge for effective TB control. Limited therapeutic options and poor treatment outcomes of DR-TB may increase drug-resistance rates. The objective of the study is to retrospectively compare MDR-TB and pre-XDR-TB treatment regimens and outcomes in two large TB reference centres in Italy from January 2000 to January 2015.

Methods

A retrospective, multicentre study was conducted at the Regional TB Reference Centre Villa Marelli Institute (Milan) and at the Reference Center for MDR-TB and HIV-TB, Eugenio Morelli Hospital (Sondalo). The supra-national Reference Laboratory in Milan performed DST. Inclusion criteria were: age ≥ 18 and culture-confirmed diagnosis of MDR- or pre-XDR TB. Chi-square or Fisher exact test was used to detect differences in the comparison between treatment outcomes, therapeutic regimens, and drug-resistances. Computations were performed with STATA 15.

Results

A total of 134 patients were selected. Median (IQR) age at admission was 33 (26–41) years and 90 patients (67.2%) were male. Pulmonary TB was diagnosed in 124 (92.5%) patients. MDR- and pre-XDR-TB cases were 91 (67.9%) and 43 (32.1%), respectively. The WHO shorter MDR-TB regimen could have been prescribed in 16/84 (19.1%) patients. Treatment success was not statistically different between MDR- and pre-XDR-TB (81.3% VS. 81.4%; P = 0.99). Mortality in MDR-TB and pre-XDR-TB groups was 4.4 and 9.3%, respectively (P = 0.2). Median duration of treatment was 18 months and a total of 110 different regimens were administered. Exposure to linezolid, meropenem, and amikacin was associated with a better outcome in both groups (P = 0.001, P < 0.001, and P = 0.004, respectively).

Conclusions

Tailored treatment regimens based on DST results can achieve successful outcomes in patients with pre-XDR-TB.

Two year outcome in treatment-naive patients with neovascular age-related macular degeneration (nAMD) using an individualized regimen of Aflibercept

PURPOSE

To evaluate the 2 year visual and anatomical results of intravitreal aflibercept injection (IAI) in nAMD in treatment-naive eyes in real life using a flexible regimen combining a PRN and modified treat-and-extend (TAE) regimen.

PATIENTS AND METHODS

This is a retrospective study including 48 eyes of 38 patients with nAMD treated with aflibercept as first line therapy. The modified T&E protocol consisted of a loading phase with 3 monthly IAI followed by an adaptation phase during which patients were monitored and treated as needed at the same visit from week 12 to week 32, then a T&E phase per se, for which the treatment interval was determined based on history of disease recurrence.

RESULTS

A total of 48 eyes were included. Visual acuity at baseline was 57.3±16 letters. Visual gain was 6±12 letters at 1 year and 5.2±11 letters at 2 years. At the 2-year end point, 94.3% of eyes maintained visual acuity and 71.4% of eyes had ≥70 letters. Reduction of central macular thickness, macular volume and pigment epithelium detachment height was observed after the loading phase, at 1 and 2 years compared to baseline. Complete resolution of fluid was obtained in 78% of eyes after the loading phase, in 68% of eyes at 1 year and in 62.8% of eyes at 2 years. Subfoveal choroidal thickness remained stable during the study. The surface area of the neovascular lesion was reduced at 1 year. The mean number of IAI was 6 IVT (3-11) during the first year and 3.2 IVT (0-13) during the second year.

CONCLUSION

Aflibercept is effective in real life in treatment-naive eyes at two years. A personalized regimen of IAI for neovascular AMD produced good functional and anatomical outcome over 2 years, with a lower number of injections than in the pivotal studies.