Global burden of MDR-TB and XDR-TB attributable to high fasting plasma glucose from 1990 to 2019: a retrospective analysis based on the global burden of disease study 2019

PURPOSE

High fasting plasma glucose (HFPG) has been identified as a risk factor for drug-resistant tuberculosis incidence and mortality. However, the epidemic characteristics of HFPG-attributable multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) remain unclear. We aimed to analyze the global spatial patterns and temporal trends of HFPG-attributable MDR-TB and XDR-TB from 1990 to 2019.

METHODS

Utilizing data from the Global Burden of Disease 2019 project, annual deaths and disability-adjusted life years (DALYs) of HFPG-attributable MDR-TB and XDR-TB were conducted from 1990 to 2019. Joinpoint regression was employed to quantify trends over time.

RESULTS

From 1990 to 2019, the deaths and DALYs due to HFPG-attributable MDR-TB and XDR-TB globally showed an overall increasing trend, with a significant increase until 2003 to 2004, followed by a gradual decline or stability thereafter. The low sociodemographic index (SDI) region experienced the most significant increase over the past 30 years. Regionally, Sub-Saharan Africa, Central Asia and Oceania remained the highest burden. Furthermore, there was a sex and age disparity in the burden of HFPG-attributable MDR-TB and XDR-TB, with young males in the 25-34 age group experiencing higher mortality, DALYs burden and a faster increasing trend than females. Interestingly, an increasing trend followed by a stable or decreasing pattern was observed in the ASMR and ASDR of HFPG-attributable MDR-TB and XDR-TB with SDI increasing.

CONCLUSION

The burden of HFPG-attributable MDR-TB and XDR-TB rose worldwide from 1990 to 2019. These findings emphasize the importance of routine bi-directional screening and integrated management for drug-resistant TB and diabetes.

Social determinants of multidrug-resistant tuberculosis: A scoping review and research gaps

Tuberculosis is a prime example of a social disease that requires social, economic and environmental interventions. However, research on social determinants of Multidrug-Resistant (MDR-TB) is limited. The five-stage scoping review showed the most common association of MDR-TB with multidimensional poverty (income, nutrition, education and social support) both as a contributing factor and a consequence of it. The review also found that physical environment (inadequate housing, overcrowding, poor physical environment, and smoking), health care needs, cultural determinants (race, ethnicity and gender), comorbidities had a strong influence on the development and transmission of MDR-TB. Since, epidemiology and care for MDR-TB are greatly influenced by socioeconomic factors, social, environmental and economic actions are needed in addition to the implementation of novel diagnostic techniques and treatments.

Improved treatment outcome of multidrug-resistant tuberculosis with the use of a rapid molecular test to detect drug resistance in China

OBJECTIVES

Numerous studies investigate the advantages of rapid molecular drug susceptibility testing (DST) in comparison to phenotypic DST, but the clinical impact on treating multi/extensively drug resistant TB(M/XDR-TB) is less studied. Therefore, we examined how molecular DST testing may improve MDR-TB treatment management and outcome in Chinese settings.

METHODS

We performed a comparative study of patient cohorts before and after the implementation of molecular DST diagnosis with Genotype MTBDRsl/MTBDRplus assay in two Chinese hospitals. We collected clinical information including time to sputum culture conversion and final treatment outcome.

RESULTS

In total, 242 MDR-TB patients were studied including 114 before (pre-implementation group) and 128 after the implementation (post-implementation group) of molecular DST. Time to MDR-TB diagnosis was significantly reduced for patients in the post-implementation group, as compared to the pre-implementation group (median,16 vs 62 days; P < 0.001). Patients with early available molecular DST results had a more rapid culture conversion (aHR1.94 95% CI: 1.37-2.73; median,12 vs 24 months, respectively; P < 0.001) and higher rate of treatment success (68% vs 47%, P < 0.01).

CONCLUSIONS

The use of molecular DST in routine care for MDR-TB diagnosis as compared to phenotypic DST was associated with a decreased time to culture conversion and improved treatment outcome, highlighting its important clinical value.

Closure of pulmonary cavity of a multidrug-resistant tuberculosis patient with catheter insertion - A case report

The treatment of multidrug-resistant tuberculosis (MDR-TB) relies heavily on optimal chemotherapy, but interventional therapies can be adopted as adjuvant treatment to speed up illness control and increase the cure rate. We present a case of a 31-year-old MDR-TB male patient with a massive pulmonary cavity in the right lower lung cured by chemotherapy with a catheter inserted in the cavity as adjuvant treatment. This case illustrated that early interventional therapy increases the treatment success rate for pulmonary MDR-TB patients with empyema and massive cavity without the need of major invasive surgery and consequently preserve lung functions.

A comparison of Rv0559c and Rv0560c expression in drug-resistant Mycobacterium tuberculosis in response to first-line antituberculosis drugs

Drug resistance to Mycobacterium tuberculosis is a major health problem worldwide. Mycobacterium tuberculosis can progress to be mono-drug resistant or multi-drug resistant by improper treatment. The chemical stress of M. tuberculosis was performed in this study. Rv0559c is an unknown secreted protein. Rv0560c is a putative benzoquinone methyltransferase of M. tuberculosis cell. Rv0559c gene is located downstream of Rv0560c gene. Both genes respond to salicylate stress. Drug susceptible, isoniazid resistant, rifampicin resistant and multi-drug resistant phenotypes of M. tuberculosis clinical isolates were used to determine the expression of Rv0559c and Rv0560c by qRT-PCR. In all of mycobacteria strains there was up-regulation in both genes when stressed with isoniazid. This study determined the expression of both genes, which may play important roles in the drug resistance mechanism of mycobacteria.

Delamanid and bedaquiline to treat multidrug-resistant and extensively drug-resistant tuberculosis in children: a systematic review

The new drugs delamanid and bedaquiline are increasingly used to treat multidrug-resistant (MDR-) and extensively drug-resistant tuberculosis (XDR-TB). As evidence is lacking, the World Health Organization recommends their use under specific conditions in adults, delamanid only being recommended in children ≥6 years of age. No systematic review has yet evaluated the efficacy, safety and tolerability of the new drugs in children. A search of peer-reviewed, scientific evidence was performed, to evaluate the efficacy/effectiveness, safety, and tolerability of delamanid or bedaquiline-containing regimens in children with confirmed M/XDR-TB. We used PubMed and Embase to identify any relevant manuscripts in English until 31 December 2016, excluding editorials and reviews. Three out of 96 manuscripts retrieved satisfied the inclusion criteria, while 93 were excluded because dealing exclusively with adults (12: 4 on delamanid and 8 on bedaquiline), being recommendations or guidelines (8 manuscripts), reviews (17 papers) or other studies (56 papers). One of the studies retrieved reported evidence on 19 M/XDR-TB children, 16 of them treated under compassionate use with delamanid (13 achieving consistent bacteriological conversion) and 3 candidates for the drug. Two studies reported details on the first paediatric case treated (and cured) with a delamanid-containing regimen. Eight trials including children were also retrieved (clinicaltrials.gov). Although the methodology used in the study was rigorous, the results are limited by the paucity of the studies available in the literature on the use of new anti-TB drugs in children. In conclusion, more evidence is needed on the use of delamanid and bedaquiline in paediatric patients.

Diagnostic accuracy and usefulness of the Genotype MTBDRplus assay in diagnosing multidrug-resistant tuberculosis in Cameroon? a cross-sectional study

Background

Drug-resistant tuberculosis, especially multidrug-resistant tuberculosis (MDR-TB), is a major public health problem. Effective management of MDR-TB relies on accurate and rapid diagnosis. In this study, we assessed the diagnostic accuracy of the Genotype MTBDRplus assay in diagnosing MDR-TB in Cameroon, and then discuss on its utility within the diagnostic algorithm for MDR-TB.

Methods

In this cross-sectional study, 225 isolates of Mycobacterium tuberculosis cultured from sputum samples collected from new and previously treated pulmonary tuberculosis patients in Cameroon were used to determine the accuracy of the Genotype MTBDRplus assay. We compared the results of the Genotype MTBDRplus assay with those from the automated liquid culture BACTEC MGIT 960 SIRE system for sensitivity, specificity, and degree of agreement. The pattern of mutations associated with resistance to RIF and INH were also analyzed.

Results

The Genotype MTBDRplus assay correctly identified Rifampicin (RIF) resistance in 48/49 isolates (sensitivity, 98% [CI, 89%–100%]), Isoniazid (INH) resistance in 55/60 isolates (sensitivity 92% [CI, 82%–96%]), and MDR-TB in 46/49 (sensitivity, 94% [CI, 83%–98%]). The specificity for the detection of RIF-resistant and MDR-TB cases was 100% (CI, 98%–100%), while that of INH resistance was 99% (CI, 97%–100%). The agreement between the two tests for the detection of MDR-TB was very good (Kappa = 0.96 [CI, 0.92–1.00]). Among the 3 missed MDR-TB cases, the Genotype MTBDRplus assay classified two samples as RIF-monoresistant and one as INH monoresistant.

The most frequent mutations detected by the Genotype MTBDRplus assay was the rpoB S531 L MUT3 41/49 (84%) in RIF-resistant isolates, and the KatG S315 T1 (MUT1) 35/55 (64%) and inhA C15T (MUT1) 20/55 (36%) mutations in INH-resistant isolates.

Conclusion

The Genotype MTBDRplus assay had good accuracy and could be used for the diagnosis of MDR-TB in Cameroon. For routine MDR-TB diagnosis, this assay could be used for Mycobacterium tuberculosis cultures containing contaminants, to complement culture-based drug susceptibility testing or to determine drug resistant mutations.

A study of clinical profile of cases of MDR-TB and evaluation of challenges faced in initiation of second line Anti tuberculosis treatment for MDR-TB cases admitted in drug resistance tuberculosis center

OBJECTIVES

To study the clinical profile of cases, evaluation of comorbidities and problems encountered in initiation of second-line drugs for multidrug-resistant tuberculosis (MDR-TB) patients.

METHODOLOGY

A prospective observational study was conducted on MDR patients admitted in drug resistance tuberculosis (DRTB) center of RDGMC Surasa Ujjain, a rural medical college, over a span of one year.

RESULTS

Out of 130 admitted cases, majority (30%) were between 31 and 40 years of age. Males were predominant (70%). Females were significantly younger compared to males (p=0.00308). Most patients (83.8%) were underweight (body mass index (BMI)<18.5kg/m²). According to MDR-TB suspect criteria, majority were defaulter cases (39.23%). The anemia was the most common comorbidity (73.84%) among the study group followed by diabetes mellitus (9.23%), chronic obstructive pulmonary disease (COPD) (9.23%), 10 (7.69) asthma, 10 (7.69%) thyroid disease 9 (6.92%) followed by respiratory insufficiency 4 (3%), HIV 2 (1.5%), deep venous thrombosis (DVT) 2 (1.5%), renal failure 2 (1.5%), and hepatic failure 1 (0.76%). Majority had minimal lesion - 57 (43.8%), moderate - 38 (29.2%), and moderate advanced - 23 (17.7%) while far advanced was noted on X-rays in 12 (9.2%). A total of 91 (70%) cases had non-cavitary lesions and 39 (30%) had cavitary lesions, of which 27 were unilateral and 12 were bilateral.

CONCLUSION

The males were predominant in our study however females were affected at a younger age compared to the males. Most of the patients had taken Anti tuberculosis treatment (ATT) from Revised National Tuberculosis Control Program (RNTCP) in which defaulter and relapse were the major contributors of MDR-TB cases in our study. Radiological extent of lesions of these patients was less than expectation. Management of comorbidities is essential for compliance to treatment. It necessitates prolonged hospitalization and requires frequent follow-up in the DRTB center.

Multidrug-resistant tuberculosis (MDR-TB) disease burden in China: a systematic review and spatio-temporal analysis

BACKGROUND

Surveillance data on the proportion of incident TB cases with MDR was limited and there is no systematic study of MDR-TB in China to date. Our aim was to estimate MDR-TB disease burden in 2012 and change trends during 2003-2012 using spatio-temporal systematic analysis.

METHODS

We systematically searched Chinese and English databases for primary articles and reviews that contain MDR-TB survey data about China during the period of 2003-2012. We estimated the proportion of incident TB cases with MDR in cities which had no data to report in 2012 by Kriging spatial interpolation analysis. The primary outcomes were the proportion of incident TB cases with MDR at 2012 and the change trend during 2003-2012.

RESULTS

Total 487 articles met the screening criteria, including 450 in Chinese and 37 in English, and have been used in analysis. The proportion of incident TB cases with MDR among all cases in 2012 showed clear geographic differences. From 2003 to 2012, the proportion of incident TB cases with MDR in all, new and previously treated TB cases were higher during 2006-2009 and significantly lower during 2010-2012 in comparison with the period during 2003-2005 (P < 0.0167). The estimated median proportion of incident TB cases with MDR among all cases, as well as in new and previously treated cases in 2012 was 12.8% (IQR 9.8-17.3%), 5.4% (4.5-7.3%) and 28.5% (20.5-30.9%) respectively, which led to an estimate of 121,600 (IQR93,000-164,350) MDR-TB cases in China.

CONCLUSIONS

This estimate of MDR-TB burden is considerably higher than data reported by the Chinese fifth national tuberculosis epidemiological sampling survey in 2010 but close to the WHO report, which implies that detailed investigations of MDR-TB burden in China is needed. This research provides data to guide public health decisions at various scales; methods described here can be extended to estimate of the other chronic diseases as well.

Systematic review and meta-analysis of the efficacy and safety of therapy with linezolid containing regimens in the treatment of multidrug-resistant and extensively drug-resistant tuberculosis

BACKGROUND

Linezolid containing regimens have been proposed as potentially valuable alternatives for the treatment of patients with multidrug-resistant tuberculosis (MDR-TB) or extensively drug-resistant TB (XDR-TB).

METHODS

A systematic review and meta-analysis was conducted to assess the efficacy, safety and tolerability of linezolid for drug-resistant TB (DR-TB) treatment. We searched the Cochrane Controlled Trial Registry, PubMed, Embase, Science Citation Index Expanded (SCI) and China National Knowledge Infrastructure (CNKI), database up to May 2014 to identify studies providing data of the use of linezolid for the treatment of DR-TB.

RESULTS

The search yielded 15 studies (367 patients) including one randomized controlled trial (RCT), covering 239 patients who could be evaluated for effectiveness; 83% [95% confidence interval (CI), 75-90%; I(2)=62.8%] had a favorable outcome, defined as either cure or treatment completion. The pooled rate of culture conversion was 89% (95% CI, 83-95%; I(2)=49.6%). Between the group receiving daily linezolid doses of ≤600 or >600 mg, the mortality was considerably lower in patients treated with less than 600 mg/day (P value <0.001). Of 367 patients for whom data on safety was available, peripheral neuropathy (31%, 95% CI, 19-42%; I(2)=81.7%) and anemia (25%, 95% CI, 15-34%; I(2)=76.6%) were the main adverse effects. Patients receiving less than 600 mg/day were more likely to experience nervous system adverse events (P value <0.01).

CONCLUSIONS

The available evidence suggests that linezolid could be considered as a promising option as treatment of MDR/XDR TB. Randomized trials are warranted to define the dose and frequency of administration.

Factors associated with treatment success and death in cases with multidrug-resistant tuberculosis in Bulgaria, 2009-2010

OBJECTIVE

To analyze determinants of success and death in multidrug-resistant tuberculosis patients (MDR-TB; resistance to, at least, isoniazid and rifampicin) placed on treatment in Bulgaria during the period September 2009 to March 2010 using logistic regression.

RESULTS

Fifty MDR-TB patients started treatment. Male:Female ratio was 2.3:1; mean age 43 years (range: 18-77); 19 patients (38%) were new; median duration of disease before treatment was 5 years (range: 1-13). All patients tested negative for HIV. Eight cases had XDR-TB (MDR-TB plus resistance to any fluoroquinolone and any second-line injectable). Twenty-four months after starting treatment, 24 patients (48%) had a successful outcome, in 6 (12%) treatment failed, 19 (38%) died, and one (2%) interrupted treatment. XDR-TB cases experienced higher mortality than others (75% vs. 30.9%, respectively, P<0.05). Sputum smear positivity at start of treatment and weight loss or no weight gain were positively associated with death (adjusted Odds ratio: 5.16; 95% confidence interval: 1.16-22.84 and 5.61; 1.48-21.20, respectively) and negatively with success (0.13; 0.02-0.94 and 0.02; 0.00-0.19). No previous TB treatment increased likelihood of success (7.82; 1.09-56.15).

DISCUSSION AND CONCLUSIONS

Most MDR-TB patients in this first treatment cohort using WHO-recommended norms had advanced disease explaining the high mortality and low success. Early, adequate treatment of MDR-TB patients can improve outcomes and avert transmission.

Epidemiology and genetic diversity of multidrug-resistant tuberculosis in East Africa

Multidrug-resistant tuberculosis (MDR-TB) is an emerging problem in many parts of the world, and levels of MDR-TB among new TB patients are increasing in sub-Saharan Africa. We reviewed the prevalence and molecular epidemiology of MDR-TB in East Africa, including Burundi, Kenya, Rwanda, Tanzania, and Uganda. In 16 epidemiologic surveys, the prevalence of MDR among new cases ranges from 0.4% in Tanzania to 4.4% in Uganda, and among recurrent cases ranges from 3.9% in Tanzania to 17.7% in Uganda. There is a gap of 5948 cases between the estimated number of MDR-TB cases in East Africa and the number actually diagnosed. The only confirmed risk factors for MDR-TB are prior treatment for TB and refugee status. HIV has not been reported as a risk factor, and there are no reports of statistical association between spoligotype and drug resistance pattern. Increased capacity for diagnosis and treatment of MDR-TB is needed, with an emphasis on recurrent TB cases and refugees.

Brazilian experience in the management of multidrug-resistance

In this article the author reviews the evolution of the approach to multidrug-resistant tuberculosis (MDR-TB) in Brazil following the introduction of rifampicin associated to isoniazid and pyrazinamide (RHZ). It shows Brazil was one of the world's first countries to use the RHZ regimen within a treatment system, with a first line regimen, another one specific for meningo-encephalic forms, for re-treatment of recurrences or of patients who returned with active tuberculosis after abandoning treatment, and a reserve regimen. The system was applied nationwide with guaranteed cost-free provision of medication, and self-administered. The author evaluates the growth of drug resistance, the emergence of multidrug-resistance and how management of this form of the disease has been organised.