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Arconada Alvarez SJ, Hoover AT, Greenleaf M, Ray SM, Schechter MC, Blumberg HM, Lam WA. "An app is just available at all times"-the process and outcomes of converting the Georgia Tuberculosis Reference Guide into a mobile application. PLoS One 2024; 19:e0298758. [PMID: 38753810 PMCID: PMC11098468 DOI: 10.1371/journal.pone.0298758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/31/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND The physical, paper-based Georgia TB Reference Guide has served as the clinical reference handbook on tuberculosis (TB) diagnostic and treatment guidelines for the state of Georgia in the United States. Supported by the Georgia Department of Public Health, the production of the 112-page palm-sized booklet was previously led by a team of Georgia-based TB experts at Emory University and printed every three-five years with updates to clinical management guidelines and TB consult contact information. However, the costs associated with editorial printing combined with delays in updating a static printed booklet with revised guidance hampered the utility of the tool. Considering the barriers with paper-based production and based on the beneficial use of apps to support the dissemination of clinical management guidance in other settings, the booklet was converted into a mobile application. This paper describes the process of developing a mobile app version of the Georgia TB Reference Guide in an easy-to-update and readily available format. METHODS We employed a user-centered design approach to develop the app, including a series of qualitative interviews and quantitative surveys. Participants included a mix of state officials and local TB experts. First, initial foundational interviews were conducted to conceptualize current utilization practices of both the paper and PDF versions of the tool. Second, the findings from the initial interviews were organized thematically and informed the design of the app, which was then beta tested by a round of previously unsampled TB experts as well as a re-sample from the initial interviews. Third, the designs were coded into developmental phases and beta tested among users of the current Georgia TB Reference Guide. Fourth, the app was published and downloaded by a pre-selected group of local users who provided answers to a follow-up survey after using the app for one month. Fifth, user growth, self-reported demographics, and app usage between February and July 2022 were recorded through automatic data metrics built into the app. RESULTS The paper copy Georgia TB Reference Guide usage themes included commonly referenced content, navigation paths, and desired features and content. The themes were converted into features and designs such as prioritizing commonly reviewed topics and guide customization with bookmarks and notes. Iterations of the designs were driven by feedback from TB experts and included home page featured content, improving content readability, and improving the search feature. The follow-up survey revealed a 90% preference for the app over the paper version of the guide. In the six months following the app's release, the app was downloaded by 281 individuals in the United States. The majority of downloads were in Georgia and the app also expanded organically to 19 other states. CONCLUSION The experience of converting the Georgia TB Reference Guide offers specific and effective steps to converting a medical reference guide into a mobile application tool that is readily available, easy to use, and easy to update. The organic dissemination of the app beyond the state of Georgia's borders within the first six months of app launch underscores desire among TB healthcare professionals for high-quality digital reference content outside the state. This experience offers clear outlines for replication in other contexts and demonstrates the utility of similar mobile medical reference tools.
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Affiliation(s)
- Santiago J. Arconada Alvarez
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- AppHatchery, Georgia Clinical and Translational Science Alliance, Atlanta, Georgia, United States of America
| | - Alison T. Hoover
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Morgan Greenleaf
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- AppHatchery, Georgia Clinical and Translational Science Alliance, Atlanta, Georgia, United States of America
| | - Susan M. Ray
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Grady Memorial Hospital, Atlanta, Georgia, United States of America
- Georgia Department of Public Health Tuberculosis Program, Atlanta, Georgia, United States of America
| | - Marcos C. Schechter
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Grady Memorial Hospital, Atlanta, Georgia, United States of America
- Georgia Department of Public Health Tuberculosis Program, Atlanta, Georgia, United States of America
| | - Henry M. Blumberg
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Grady Memorial Hospital, Atlanta, Georgia, United States of America
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Wilbur A. Lam
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- AppHatchery, Georgia Clinical and Translational Science Alliance, Atlanta, Georgia, United States of America
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, United States of America
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States of America
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Salindri AD, Kipiani M, Lomtadze N, Tukvadze N, Avaliani Z, Blumberg HM, Masyn KE, Rothenberg RB, Kempker RR, Magee MJ. HIV co-infection increases the risk of post-tuberculosis mortality among persons who initiated treatment for drug-resistant tuberculosis. medRxiv 2024:2023.05.19.23290190. [PMID: 37293036 PMCID: PMC10246159 DOI: 10.1101/2023.05.19.23290190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Little is known regarding the relationship between common comorbidities in persons with tuberculosis (TB) (including human immunodeficiency virus [HIV], diabetes, and hepatitis C virus [HCV]) with post-TB mortality. We conducted a retrospective cohort study among persons who initiated treatment for rifampicin-resistant and multi/extensively drug-resistant (RR and M/XDR) TB reported to the country of Georgia's TB surveillance during 2009-2017. Exposures included HIV serologic status, diabetes, and HCV status. Our outcome was all-cause post-TB mortality determined by cross-validating vital status with Georgia's death registry through November 2019. We estimated adjusted hazard rate ratios (aHR) and 95% confidence intervals (CI) of post-TB mortality among participants with and without comorbidities using cause-specific hazard regressions. Among 1032 eligible participants, 34 (3.3%) died during treatment and 87 (8.7%) died post-TB treatment. Among those who died post-TB treatment, the median time to death was 21 months (interquartile range 7-39) post-TB treatment. After adjusting for confounders, the hazard rates of post-TB mortality were higher among participants with HIV co-infection (aHR=3.74, 95%CI 1.77-7.91) compared to those without HIV co-infection. In our cohort, post-TB mortality occurred most commonly in the first three years post-TB treatment. Linkage to care for common TB comorbidities post-treatment may reduce post-TB mortality rates.
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Affiliation(s)
- Argita D. Salindri
- Department of Population Health Sciences, Georgia State University School of Public Health, Atlanta, GA, USA; and Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia; David Tvildiani Medical University, Tbilisi, Georgia; and The University of Georgia, Tbilisi, Georgia
| | - Nino Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia; David Tvildiani Medical University, Tbilisi, Georgia; and The University of Georgia, Tbilisi, Georgia
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia; and Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia; and European University, Tbilisi, Georgia
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Hubert Department of Global Health and Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Katherine E. Masyn
- Department of Population Health Sciences, Georgia State University School of Public Health, Atlanta, GA, USA, Atlanta, GA, USA
| | - Richard B. Rothenberg
- Department of Population Health Sciences, Georgia State University School of Public Health, Atlanta, GA, USA, Atlanta, GA, USA
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew J. Magee
- Hubert Department of Global Health and Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA; and Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Ogongo P, Wassie L, Tran A, Columbus D, Sharling L, Ouma G, Ouma SG, Bobosha K, Lindestam Arlehamn CS, Gandhi NR, Auld SC, Rengarajan J, Day CL, Altman JD, Blumberg HM, Ernst JD. Rare Variable M. tuberculosis Antigens induce predominant Th17 responses in human infection. bioRxiv 2024:2024.03.05.583634. [PMID: 38496518 PMCID: PMC10942433 DOI: 10.1101/2024.03.05.583634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
CD4 T cells are essential for immunity to M. tuberculosis (Mtb), and emerging evidence indicates that IL-17-producing Th17 cells contribute to immunity to Mtb. While identifying protective T cell effector functions is important for TB vaccine design, T cell antigen specificity is also likely to be important. To identify antigens that induce protective immunity, we reasoned that as in other pathogens, effective immune recognition drives sequence diversity in individual Mtb antigens. We previously identified Mtb genes under evolutionary diversifying selection pressure whose products we term Rare Variable Mtb Antigens (RVMA). Here, in two distinct human cohorts with recent exposure to TB, we found that RVMA preferentially induce CD4 T cells that express RoRγt and produce IL-17, in contrast to 'classical' Mtb antigens that induce T cells that produce IFNγ. Our results suggest that RVMA can be valuable antigens in vaccines for those already infected with Mtb to amplify existing antigen-specific Th17 responses to prevent TB disease.
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Affiliation(s)
- Paul Ogongo
- Division of Experimental Medicine, University of California, San Francisco, CA, USA
- Department of Tropical and Infectious Diseases, Institute of Primate Research, Nairobi, Kenya
| | - Liya Wassie
- Mycobacterial Disease Research Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Anthony Tran
- Division of Experimental Medicine, University of California, San Francisco, CA, USA
| | - Devin Columbus
- Division of Experimental Medicine, University of California, San Francisco, CA, USA
| | - Lisa Sharling
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Gregory Ouma
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Samuel Gurrion Ouma
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Kidist Bobosha
- Mycobacterial Disease Research Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | | | - Neel R. Gandhi
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Sara C. Auld
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jyothi Rengarajan
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Emory Vaccine Center, Emory University, Atlanta, GA, USA
| | - Cheryl L. Day
- Emory Vaccine Center, Emory University, Atlanta, GA, USA
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA
| | - John D. Altman
- Emory Vaccine Center, Emory University, Atlanta, GA, USA
| | - Henry M. Blumberg
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Joel D. Ernst
- Division of Experimental Medicine, University of California, San Francisco, CA, USA
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Collins JM, Kipiani M, Jin Y, Sharma AA, Tomalka JA, Avaliani T, Gujabidze M, Bakuradze T, Sabanadze S, Avaliani Z, Blumberg HM, Benkeser D, Jones DP, Peloquin C, Kempker RR. Pharmacometabolomics in TB Meningitis - understanding the pharmacokinetic, metabolic, and immune factors associated with anti-TB drug concentrations in cerebrospinal fluid. medRxiv 2023:2023.12.14.23299982. [PMID: 38168338 PMCID: PMC10760251 DOI: 10.1101/2023.12.14.23299982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Poor penetration of many anti-tuberculosis (TB) antibiotics into the central nervous system (CNS) is thought to be a major driver of morbidity and mortality in TB meningitis (TBM). While the amount of a particular drug that crosses into the cerebrospinal fluid (CSF) varies from person to person, little is known about the host factors associated with interindividual differences in CSF concentrations of anti-TB drugs. In patients diagnosed with TBM from the country of Georgia (n=17), we investigate the association between CSF concentrations of anti-TB antibiotics and multiple host factors including serum drug concentrations and CSF concentrations of metabolites and cytokines. We found >2-fold differences in CSF concentrations of anti-TB antibiotics from person to person for all drugs tested including cycloserine, ethambutol, imipenem, isoniazid, levofloxacin, linezolid, moxifloxacin pyrazinamide, and rifampin. While serum drug concentrations explained over 40% of the variation in CSF drug concentrations for cycloserine, isoniazid, linezolid, and pyrazinamide (adjusted R 2 >0.4, p<0.001 for all), there was no evidence of an association between serum concentrations of imipenem and ethambutol and their respective CSF concentrations. CSF concentrations of carnitines were significantly associated with concentrations of ethambutol and imipenem (q<0.05), and imipenem was the only antibiotic significantly associated with CSF cytokine concentrations. These results indicate that there is high interindividual variability in CSF drug concentrations in patients treated for TBM, which is only partially explained by differences in serum drug concentrations and not associated with concentrations of cytokines and chemokines in the CSF.
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Jin Y, Benkeser D, Kipiani M, Maranchick NF, Mikiashvili L, Barbakadze K, Avaliani Z, Alghamdi WA, Alshaer MH, Peloquin CA, Blumberg HM, Kempker RR. The effect of anti-tuberculosis drug pharmacokinetics on QTc prolongation. Int J Antimicrob Agents 2023; 62:106939. [PMID: 37517627 PMCID: PMC10538394 DOI: 10.1016/j.ijantimicag.2023.106939] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/19/2023] [Accepted: 07/26/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Implementation of newer anti-tuberculosis (TB) drugs may prolong the QT interval, increasing the risk of arrythmias and sudden cardiac death. The potential for cardiac adverse events has prompted recommendations for frequent cardiac monitoring during treatment. However, unknowns remain, including the association between drug concentrations and QT interval. METHODS An observational prospective cohort study design was used. Patients undergoing treatment for drug-resistant TB in Georgia were assessed. Serial blood samples were collected at 4-6 weeks for pharmacokinetics. Electrocardiograms were recommended to be performed monthly. A generalized estimating equation spline model was used to investigate (1) the effect difference between bedaquiline and delamanid, (2) the cumulative effect of number of anti-TB drugs, and (3) the relationship between serum drug concentrations on QTc interval. RESULTS Among 94 patients receiving either bedaquiline (n = 64) or delamanid (n = 30)-based treatment, most were male (82%), and the mean age was 39 years. The mean maximum QTc increase during the first six months was 37.5 ms (IQR: 17.8-56.8). Bedaquiline- and delamanid-based regimens displayed similar increased mean QTc change from baseline during drug administration (P = 0.12). Increasing number of anti-TB drugs was associated with an increased QTc (P = 0.01), but participants trended back towards baseline after drug discontinuation (P = 0.25). A significant association between AUC, Cmin, Cmax, and increased QTc interval was found for bedaquiline (months 1-6) and levofloxacin (months 1-12). CONCLUSION Bedaquiline- and delamanid-based regimens and increasing number of QT prolonging agents led to modest increases in the QTc interval with minimal clinical effect.
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Affiliation(s)
- Yutong Jin
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia
| | - David Benkeser
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | | | - Lali Mikiashvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | | | - Zaza Avaliani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Wael A Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | | | | | - Henry M Blumberg
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia.
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McGee RE, Blumberg HM, Ziegler TR, Ofotokun I, Bhatti PT, Paulsen DF, Quarshie A, Somanath PR, Comeau DL. Mentor training for junior faculty: a brief evaluation report from the Georgia Clinical and Translational Science Alliance. J Investig Med 2023; 71:577-585. [PMID: 37085987 PMCID: PMC10989736 DOI: 10.1177/10815589231168601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
To provide a foundation for mentoring, junior faculty participated in a mentor training workshop informed by the Mentoring Clinical and Translational Researchers curriculum. The goal was to develop skills and behaviors that engender more rewarding and inclusive mentoring practices. Attendees responded to baseline and follow-up surveys assessing perceived mentoring skills. Follow-up surveys included closed- and open-ended questions about the value and satisfaction of the training, and intended behavior changes. Junior faculty respondents (n = 39) reported significantly higher overall mentoring skills after the training (t = -2.6, p = 0.012) with a medium effect size (Cohen's D = 0.59). Domains with statistically significant improvement from baseline to follow-up included aligning mentor-mentee expectations and assessing understanding. Thirty-eighty (97%) found the training valuable, and 32 (82%) indicated they would change mentoring-related behaviors because of the training. Intended behavior changes described in open-ended responses aligned with mentoring skills assessed (e.g., aligning expectations). An additional competency domain of evaluating mentoring relationships was also described. A mentor training workshop for junior faculty appeared to contribute to changes in mentoring skills and intended behaviors. Mentor training has the potential to enhance mentorship, which is critical to strengthening a diverse pipeline of clinical and translational science researchers.
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Affiliation(s)
- Robin E McGee
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Henry M Blumberg
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Emory University, Atlanta, GA, USA
- Department of Epidemiology and Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Thomas R Ziegler
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA, USA
| | - Ighovwerha Ofotokun
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Pamela T Bhatti
- School of Electrical and Computer Engineering, College of Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Douglas F Paulsen
- Department of Pathology and Anatomy, Morehouse School of Medicine, Atlanta, GA, USA
| | - Alexander Quarshie
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - Payaningal R Somanath
- Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Augusta, GA, USA
| | - Dawn L Comeau
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Baliashvili D, Blumberg HM, Gandhi NR, Averhoff F, Benkeser D, Shadaker S, Gvinjilia L, Turdziladze A, Tukvadze N, Chincharauli M, Butsashvili M, Sharvadze L, Tsertsvadze T, Zarkua J, Kempker RR. Hepatitis C care cascade among patients with and without tuberculosis: Nationwide observational cohort study in the country of Georgia, 2015-2020. PLoS Med 2023; 20:e1004121. [PMID: 37141386 PMCID: PMC10194957 DOI: 10.1371/journal.pmed.1004121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 05/18/2023] [Accepted: 04/13/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND The Eastern European country of Georgia initiated a nationwide hepatitis C virus (HCV) elimination program in 2015 to address a high burden of infection. Screening for HCV infection through antibody testing was integrated into multiple existing programs, including the National Tuberculosis Program (NTP). We sought to compare the hepatitis C care cascade among patients with and without tuberculosis (TB) diagnosis in Georgia between 2015 and 2019 and to identify factors associated with loss to follow-up (LTFU) in hepatitis C care among patients with TB. METHODS AND FINDINGS Using national ID numbers, we merged databases of the HCV elimination program, NTP, and national death registry from January 1, 2015 to September 30, 2020. The study population included 11,985 adults (aged ≥18 years) diagnosed with active TB from January 1, 2015 through December 31, 2019, and 1,849,820 adults tested for HCV antibodies between January 1, 2015 and September 30, 2020, who were not diagnosed with TB during that time. We estimated the proportion of patients with and without TB who were LTFU at each step of the HCV care cascade and explored temporal changes. Among 11,985 patients with active TB, 9,065 (76%) patients without prior hepatitis C treatment were tested for HCV antibodies, of which 1,665 (18%) had a positive result; LTFU from hepatitis C care was common, with 316 of 1,557 (20%) patients with a positive antibody test not undergoing viremia testing and 443 of 1,025 (43%) patients with viremia not starting treatment for hepatitis C. Overall, among persons with confirmed viremic HCV infection, due to LTFU at various stages of the care cascade only 28% of patients with TB had a documented cure from HCV infection, compared to 55% among patients without TB. LTFU after positive antibody testing substantially decreased in the last 3 years, from 32% among patients diagnosed with TB in 2017 to 12% among those diagnosed in 2019. After a positive HCV antibody test, patients without TB had viremia testing sooner than patients with TB (hazards ratio [HR] = 1.46, 95% confidence intervals [CI] [1.39, 1.54], p < 0.001). After a positive viremia test, patients without TB started hepatitis C treatment sooner than patients with TB (HR = 2.05, 95% CI [1.87, 2.25], p < 0.001). In the risk factor analysis adjusted for age, sex, and case definition (new versus previously treated), multidrug-resistant (MDR) TB was associated with an increased risk of LTFU after a positive HCV antibody test (adjusted risk ratio [aRR] = 1.41, 95% CI [1.12, 1.76], p = 0.003). The main limitation of this study was that due to the reliance on existing electronic databases, we were unable to account for the impact of all confounding factors in some of the analyses. CONCLUSIONS LTFU from hepatitis C care after a positive antibody or viremia test was high and more common among patients with TB than in those without TB. Better integration of TB and hepatitis C care systems can potentially reduce LTFU and improve patient outcomes both in Georgia and other countries that are initiating or scaling up their nationwide hepatitis C control efforts and striving to provide personalized TB treatment.
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Affiliation(s)
- Davit Baliashvili
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Henry M. Blumberg
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Neel R. Gandhi
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Francisco Averhoff
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - David Benkeser
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Shaun Shadaker
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Lia Gvinjilia
- Eastern Europe and Central Asia Regional Office, Centers for Disease Control and Prevention, Tbilisi, Georgia
| | | | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | | | | | - Lali Sharvadze
- Clinic “Hepa”, Tbilisi, Georgia
- The University of Georgia, Tbilisi, Georgia
| | - Tengiz Tsertsvadze
- Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | | | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
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Blumberg HM. Phantom Plague: How Tuberculosis Shaped History. Emerg Infect Dis 2023. [DOI: 10.3201/eid2903.221676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
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Baliashvili D, Blumberg HM, Benkeser D, Kempker RR, Shadaker S, Averhoff F, Gvinjilia L, Adamashvili N, Magee M, Kamkamidze G, Zakalashvili M, Tsertsvadze T, Sharvadze L, Chincharauli M, Tukvadze N, Gandhi NR. Association of Treated and Untreated Chronic Hepatitis C With the Incidence of Active Tuberculosis Disease: A Population-Based Cohort Study. Clin Infect Dis 2023; 76:245-251. [PMID: 36134743 PMCID: PMC10194043 DOI: 10.1093/cid/ciac786] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 09/12/2022] [Accepted: 09/19/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection causes dysregulation and suppression of immune pathways involved in the control of tuberculosis (TB) infection. However, data on the role of chronic hepatitis C as a risk factor for active TB are lacking. We sought to evaluate the association between HCV infection and the development of active TB. METHODS We conducted a cohort study in Georgia among adults tested for HCV antibodies (January 2015-September 2020) and followed longitudinally for the development of newly diagnosed active TB. Data were obtained from the Georgian national programs of hepatitis C and TB. The exposures of interest were untreated and treated HCV infection. A Cox proportional hazards model was used to calculate adjusted hazard ratios (aHRs). RESULTS A total of 1 828 808 adults were included (median follow-up time: 26 months; IQR: 13-39 months). Active TB was diagnosed in 3163 (0.17%) individuals after a median of 6 months follow-up (IQR: 1-18 months). The incidence rate per 100 000 person-years was 296 among persons with untreated HCV infection, 109 among those with treated HCV infection, and 65 among HCV-negative persons. In multivariable analysis, both untreated (aHR = 2.9; 95% CI: 2.4-3.4) and treated (aHR = 1.6; 95% CI: 1.4-2.0) HCV infections were associated with a higher hazard of active TB, compared with HCV-negative persons. CONCLUSIONS Adults with HCV infection, particularly untreated individuals, were at higher risk of developing active TB disease. Screening for latent TB infection and active TB disease should be part of clinical evaluation of people with HCV infection, especially in high-TB-burden areas.
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Affiliation(s)
- Davit Baliashvili
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Henry M Blumberg
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David Benkeser
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shaun Shadaker
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Francisco Averhoff
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lia Gvinjilia
- Eastern Europe and Central Asia Regional Office, Centers for Disease Control and Prevention, Tbilisi, Georgia
| | | | - Matthew Magee
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | | | | | - Tengiz Tsertsvadze
- Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Lali Sharvadze
- Clinic “Hepa”, Tbilisi, Georgia
- The University of Georgia, Tbilisi, Georgia
| | | | - Nestan Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Neel R Gandhi
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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10
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Moga S, Bobosha K, Fikadu D, Zerihun B, Diriba G, Amare M, Kempker RR, Blumberg HM, Abebe T. Diagnostic performance of the GenoType MTBDRplus VER 2.0 line probe assay for the detection of isoniazid resistant Mycobacterium tuberculosis in Ethiopia. PLoS One 2023; 18:e0284737. [PMID: 37099514 PMCID: PMC10132600 DOI: 10.1371/journal.pone.0284737] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 04/06/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Isoniazid (INH) resistant Mycobacterium tuberculosis (Hr-TB) is the most common type of drug resistant TB, and is defined as M tuberculosis complex (MTBC) strains resistant to INH but susceptible to rifampicin (RIF). Resistance to INH precedes RIF resistance in almost all multidrug resistant TB (MDR-TB) cases, across all MTBC lineages and in all settings. Therefore, early detection of Hr-TB is critical to ensure rapid initiation of appropriate treatment, and to prevent progression to MDR-TB. We assessed the performance of the GenoType MTBDRplus VER 2.0 line probe assay (LPA) in detecting isoniazid resistance among MTBC clinical isolates. METHODS A retrospective study was conducted among M. tuberculosis complex (MTBC) clinical isolates obtained from the third-round Ethiopian national drug resistance survey (DRS) conducted between August 2017 and December 2019. The sensitivity, specificity, positive predictive value, and negative predictive value of the GenoType MTBDRplus VER 2.0 LPA in detecting INH resistance were assessed and compared to phenotypic drug susceptibility testing (DST) using the Mycobacteria Growth Indicator Tube (MGIT) system. Fisher's exact test was performed to compare the performance of LPA between Hr-TB and MDR-TB isolates. RESULTS A total of 137 MTBC isolates were included, of those 62 were Hr-TB, 35 were MDR-TB and 40 were INH susceptible. The sensitivity of the GenoType MTBDRplus VER 2.0 for detecting INH resistance was 77.4% (95% CI: 65.5-86.2) among Hr-TB isolates and 94.3% (95% CI: 80.4-99.4) among MDR-TB isolates (P = 0.04). The specificity of the GenoType MTBDRplus VER 2.0 for detecting INH resistance was 100% (95% CI: 89.6-100). The katG 315 mutation was observed in 71% (n = 44) of Hr-TB phenotypes and 94.3% (n = 33) of MDR-TB phenotypes. Mutation at position-15 of the inhA promoter region alone was detected in four (6.5%) Hr-TB isolates, and concomitantly with katG 315 mutation in one (2.9%) MDR-TB isolate. CONCLUSIONS GenoType MTBDRplus VER 2.0 LPA demonstrated improved performance in detecting INH resistance among MDR-TB cases compared to Hr-TB cases. The katG315 mutation is the most common INH resistance conferring gene among Hr-TB and MDR-TB isolates. Additional INH resistance conferring mutations should be evaluated to improve the sensitivity of the GenoType MTBDRplus VER 2.0 for the detection of INH resistance among Hr-TB cases.
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Affiliation(s)
- Shewki Moga
- Ethiopian Public Health Institute (EPHI), Addis Ababa, Ethiopia
- Department of Microbiology, Immunology, and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University (AAU), Addis Ababa, Ethiopia
| | - Kidist Bobosha
- Armauer Hansen Research Institute (AHRI), Addis Ababa, Ethiopia
| | - Dinka Fikadu
- Ethiopian Public Health Institute (EPHI), Addis Ababa, Ethiopia
| | | | - Getu Diriba
- Ethiopian Public Health Institute (EPHI), Addis Ababa, Ethiopia
| | - Misikir Amare
- Ethiopian Public Health Institute (EPHI), Addis Ababa, Ethiopia
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Henry M Blumberg
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Departments of Epidemiology and Global Health, Emory Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Tamrat Abebe
- Department of Microbiology, Immunology, and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University (AAU), Addis Ababa, Ethiopia
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Graciaa DS, Kipiani M, Magee MJ, Mikiashvili L, Barbakadze K, Bablishvili N, Auld SC, Alghamdi WA, Alshaer MH, Peloquin CA, Avaliani Z, Blumberg HM, Kempker RR. Linezolid Exposure Is Associated with Cytopenias in Patients Treated for Multidrug-Resistant Tuberculosis. Antimicrob Agents Chemother 2022; 66:e0040822. [PMID: 35916515 PMCID: PMC9487506 DOI: 10.1128/aac.00408-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/17/2022] [Indexed: 02/04/2023] Open
Abstract
Although linezolid is effective for multidrug-resistant TB (MDR-TB) tuberculosis treatment, it is associated with cytopenias after 4 weeks of administration. Data on toxicities with long-term use of linezolid and drug pharmacodynamics in MDR-TB treatment are limited, and concerns about toxicity present barriers to wider implementation. This was a secondary analysis of a prospective cohort study of patients treated for MDR-TB in the country of Georgia from 2015 to 2017. Intensive blood sampling 4 to 6 weeks after treatment initiation with linezolid 600 mg daily was performed for pharmacokinetic (PK) analysis, including linezolid trough concentration (Cmin) and area under the curve from 0 to 24 hours (AUC0-24). Linezolid exposure was defined using literature-reported thresholds. Cytopenias were defined using an NIH adverse event (AE) scale. Logistic regression was used to evaluate the relationship between linezolid exposure and cytopenias. Among 76 patients receiving linezolid in their baseline treatment regimen and who had PK data available, cytopenia AEs occurred in 30 (39.5%) for an incidence rate of 46 per 100 person-years. The median duration of linezolid therapy was 526 days. No patients required dose reduction or interruption due to cytopenias. Median linezolid Cmin was 0.235 mg/L (interquartile range [IQR], 0.069 to 0.529), and median AUC0-24 was 89.6 mg·h/L (IQR, 69.2 to 116.2). Cytopenias were associated with linezolid PK parameters (Cmin > 2 mg/L and AUC0-24 > 160 mg·h/L). Cytopenias occurred frequently with long-term use of linezolid 600 mg/day and were associated with PK parameters but did not result in the need for treatment interruption in the management of a cohort of patients with MDR-TB.
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Affiliation(s)
- Daniel S. Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Matthew J. Magee
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lali Mikiashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Ketevan Barbakadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Nino Bablishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Sara C. Auld
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Wael A. Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | | | | | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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12
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Getahun M, Blumberg HM, Ameni G, Beyene D, Kempker RR. Minimum inhibitory concentrations of rifampin and isoniazid among multidrug and isoniazid resistant Mycobacterium tuberculosis in Ethiopia. PLoS One 2022; 17:e0274426. [PMID: 36099255 PMCID: PMC9469996 DOI: 10.1371/journal.pone.0274426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Traditionally, single critical concentrations of drugs are utilized for Mycobacterium tuberculosis (Mtb) drug susceptibility testing (DST); however, the level of drug resistance can impact treatment choices and outcomes. Mutations at the katG gene are the major genetic mutations in multidrug resistant (MDR) Mtb and usually associated with high level resistance. We assessed the minimum inhibitory concentrations (MICs) of MDR or rifampin resistant (RR) and isoniazid (INH) resistant Mtb isolates to determine the quantification of drug resistance among key anti-tuberculosis drugs. Methods The study was conducted on stored Mtb isolates collected as part of a national drug resistance survey in Ethiopia. MIC values were determined using Sensititre™ MYCOTB plates. A line probe assay (MTBDRplus) was also performed to identify genetic determinants of resistance for all isolates. Results MIC testing was performed on 74 Mtb isolates including 46 MDR, 2 RR and 26 INH phenotypically resistant isolates as determined by the Löwenstein Jensen (LJ) method. Four (15%) INH resistant Mtb isolates were detected as borderline rifampin resistance (MIC = 1 μg/ml) using MYCOTB MIC plates and no rifampin resistance mutations were detected by LPA. Among the 48 MDR/RR TB cases, 9 (19%) were rifabutin susceptible (MIC was between ≤0.25 and 0.5μg/ml). Additionally, the MIC for isoniazid was between 2–4 μg/ml (moderate resistance) for 58% of MDR TB isolates and 95.6% (n = 25) of the isolates had mutations at the katG gene. Conclusion Our findings suggest a role for rifabutin treatment in a subset of RR TB patients, thus potentially preserving an important drug class. The high proportion of moderate level INH resistant among MDR Mtb isolates indicates the potential benefit of high dose isoniazid treatment in a high proportion of katG gene harboring MDR Mtb isolates.
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Affiliation(s)
- Muluwork Getahun
- TB and HIV Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Department of Microbial, Cellular and Molecular Biology, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail:
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Gobena Ameni
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Veterinary Medicine, College of Agriculture and Veterinary Medicine, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Dereje Beyene
- Department of Microbial, Cellular and Molecular Biology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
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13
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Kempker RR, Smith AGC, Avaliani T, Gujabidze M, Bakuradze T, Sabanadze S, Avaliani Z, Collins JM, Blumberg HM, Alshaer MH, Peloquin CA, Kipiani M. Cycloserine and Linezolid for Tuberculosis Meningitis: Pharmacokinetic Evidence of Potential Usefulness. Clin Infect Dis 2022; 75:682-689. [PMID: 34849645 PMCID: PMC9464073 DOI: 10.1093/cid/ciab992] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The ability of antituberculosis drugs to cross the blood-brain barrier and reach the central nervous system is critical to their effectiveness in treating tuberculosis meningitis (TBM). We sought to fill a critical knowledge gap by providing data on the ability of new and repurposed antituberculosis drugs to penetrate into the cerebrospinal fluid (CSF). METHODS We conducted a clinical pharmacology study among patients treated for TBM in Tbilisi, Georgia, from January 2019 until January 2020. Serial serum and CSF samples were collected while patients were hospitalized. CSF was collected from routine lumbar punctures with the timing of the lumbar puncture alternating between 2 and 6 hours to capture early and late CSF penetration. RESULTS A total of 17 patients treated for TBM (8 with confirmed disease) were included; all received linezolid, with a subset receiving cycloserine (5), clofazimine (5), delamanid (4), and bedaquiline (2). All CSF measurements of bedaquiline (12), clofazimine (24), and delamanid (19) were below the limit of detection. The median CSF concentrations of cycloserine at 2 and 6 hours were 15.90 and 15.10 µg/mL with adjusted CSF/serum ratios of 0.52 and 0.66. CSF concentrations of linezolid were 0.90 and 3.14 µg/mL at 2 and 6 hours, with adjusted CSF/serum ratios of 0.25 and 0.59, respectively. CSF serum linezolid concentrations were not affected by rifampin coadministration. CONCLUSIONS Based on moderate to high CSF penetration, linezolid and cycloserine may be effective drugs for TBM treatment, whereas the utility of bedaquiline, delamanid, and clofazimine is uncertain given their low CSF penetration.
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Affiliation(s)
- Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | | | - Teona Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Mariam Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Tinatin Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shorena Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Jeffrey M Collins
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Henry M Blumberg
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Charles A Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- The University of Georgia, Tbilisi, Georgia
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14
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Smith AGC, Kempker RR, Wassie L, Bobosha K, Nizam A, Gandhi NR, Auld SC, Magee MJ, Blumberg HM. The Impact of Diabetes and Prediabetes on Prevalence of Mycobacterium tuberculosis Infection Among Household Contacts of Active Tuberculosis Cases in Ethiopia. Open Forum Infect Dis 2022; 9:ofac323. [PMID: 36420425 PMCID: PMC9595051 DOI: 10.1093/ofid/ofac323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/28/2022] [Indexed: 02/03/2023] Open
Abstract
Background It is uncertain whether diabetes affects the risk of developing latent tuberculosis infection (LTBI) following exposure to Mycobacterium tuberculosis (Mtb). We assessed the relationship of diabetes or prediabetes and LTBI among close and household contacts (HHCs) of patients with active pulmonary tuberculosis (TB) disease in Addis Ababa, Ethiopia. Methods In this cross-sectional study, we performed interferon-γ release assays, TB symptom screening, and point-of-care glycolated hemoglobin (HbA1c) testing among HHCs of active TB cases. Diabetes status was classified into diabetes (HbA1c ≥6.5% or self-reported diagnosis), prediabetes (5.7%-6.4%), and euglycemia (≤5.6%). Multivariable logistic regression was used to determine the association of diabetes with LTBI. Results Among 597 study participants, 123 (21%) had dysglycemia including diabetes (n = 31) or prediabetes (n = 92); 423 (71%) participants were diagnosed with LTBI. Twelve of 31 (39%) HHCs with diabetes were previously undiagnosed with diabetes. The prevalence of LTBI among HHCs with diabetes, prediabetes, and euglycemia was 87% (27/31), 73% (67/92), and 69% (329/474), respectively. In multivariable analysis adjusted for age, sex, and HIV status, the odds of LTBI among HHCs with diabetes were 2.33 (95% confidence interval [CI], .76-7.08) times the odds of LTBI without diabetes. When assessing interaction with age, the association of diabetes and LTBI was robust among participants aged ≥40 years (adjusted odds ratio [aOR], 3.68 [95% CI, .77-17.6]) but not those <40 years (aOR, 1.15 [95% CI, .22-6.1]). Conclusions HHCs with diabetes may be more likely to have LTBI than those with euglycemia. Further investigations are needed to assess mechanisms by which diabetes may increase risk of LTBI after Mtb exposure.
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Affiliation(s)
- Alison G C Smith
- Correspondence: Alison G. C. Smith, MD, MSc, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA ()
| | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Liya Wassie
- Mycobacterial Disease Research Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Kidist Bobosha
- Mycobacterial Disease Research Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Azhar Nizam
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Neel R Gandhi
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA,Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Sara C Auld
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Matthew J Magee
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA,Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia, USA,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA,Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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15
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Adamashvili N, Baliashvili D, Kuchukhidze G, Salindri AD, Kempker RR, Blumberg HM, Lomtadze N, Avaliani Z, Magee MJ. Low BMI increases all-cause mortality rates in patients with drug-resistant TB. Int J Tuberc Lung Dis 2022; 26:326-333. [PMID: 35351237 PMCID: PMC9757601 DOI: 10.5588/ijtld.21.0450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: Loss to follow-up (LTFU) is common among patients with drug-resistant TB (DR-TB) receiving second-line TB treatment; however, little is known about outcomes after LTFU, including mortality.OBJECTIVE: To determine rates of and factors associated with all-cause mortality among patients with DR-TB who were LTFU.METHODS: Retrospective cohort study of adult patients with DR-TB in Georgia who initiated second-line TB treatment during 2011-2014 and were LTFU. Survival analyses were used to estimate all-cause mortality rates and adjusted hazard ratios (aHR).RESULTS: During 2011-2014, 2,437 second-line treatment episodes occurred and 695 patients were LTFU. Among 695 LTFU patients, 143 (21%) died during 2,686 person-years (PY) post-LTFU (all-cause mortality rate 5.1%, 95% CI 4.3-6.0 per 100 PY). In multivariable analysis, low weight (BMI < 18.5 kg/m²) at treatment initiation (aHR 3.2, 95% CI 2.2-4.7), return to treatment after LTFU (aHR 3.1, 95% CI 2.2-4.4), <12 months of treatment (aHR 2.4, 95% CI 1.4-4.1) and a pre-LTFU positive culture (aHR 3.3, 95% CI 2.2-4.9) were associated with all-cause mortality.CONCLUSION: High all-cause mortality occurred among patients with DR-TB after LTFU despite a low HIV prevalence. Providing additional assistance for patients during DR-TB treatment to prevent LTFU and use of new and shorter treatment regimens may reduce mortality among LTFU.
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Affiliation(s)
- N Adamashvili
- National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - D Baliashvili
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - G Kuchukhidze
- National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - A D Salindri
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, GA
| | - R R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - H M Blumberg
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, GA, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - N Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - M J Magee
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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16
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Maghradze N, Jugheli L, Borrell S, Tukvadze N, Kempker RR, Blumberg HM, Gagneux S. Developing customized stepwise MIRU-VNTR typing for tuberculosis surveillance in Georgia. PLoS One 2022; 17:e0264472. [PMID: 35231041 PMCID: PMC8887741 DOI: 10.1371/journal.pone.0264472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/10/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction
Mycobacterial Interspersed Repetitive Units–Variable Tandem Repeats (MIRU-VNTR) typing has been widely used for molecular epidemiological studies of tuberculosis (TB). However, genotyping tools for Mycobacterium tuberculosis (Mtb) may be limiting in some settings due to high cost and workload. In this study developed a customized stepwise MIRU-VNTR typing that prioritizes high discriminatory loci and validated this method using penitentiary system cohort in the country of Georgia.
Methods
We used a previously generated MIRU-VNTR dataset from recurrent TB cases (32 cases) in Georgia and a new dataset of TB cases from the penitentiary system (102 cases) recruited from 2014 to 2015. A Hunter-Gaston Discriminatory Index (HGDI) was calculated utilizing a 24 standard loci panel, to select high discriminatory power loci, subsequently defined as the customized Georgia-specific set of loci for initial typing. The remaining loci were scored and hierarchically grouped for second and third step typing of the cohort. We then compared the processing time and costs of the customized stepwise method to the standard 24-loci method.
Results
For the customized Georgia-specific set that was used for initial typing, 10 loci were selected with a minimum value of 0.32 to the highest HGDI score locus. Customized 10 loci (step 1) typing of 102 Mtb patient isolates revealed 35.7% clustered cases. This proportion was reduced to 19.5% after hierarchical application of 2nd and 3rd step typing with the corresponding groups of loci. Our customized stepwise MIRU-VNTR genotyping approach reduced the quantity of samples to be typed and therefore overall processing time and costs by 42.6% each.
Conclusion
Our study shows that our customized stepwise MIRU-VNTR typing approach is a valid alternative of standard MIRI-VNTR typing panels for molecular epidemiological investigation in Georgia that saves time, workload and costs. Similar approaches could be developed for other settings.
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Affiliation(s)
- Nino Maghradze
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Levan Jugheli
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Sonia Borrell
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Nestani Tukvadze
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
- Departments of Epidemiology and Global Health, Rollins School of Public Health of Emory University, Atlanta, GA, United States of America
| | - Sebastien Gagneux
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- * E-mail:
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17
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Modlin CE, C. Vilorio A, Stoff B, L. Comeau D, Gebremariam TH, Derbew M, M. Blumberg H, del Rio C, Kempker RR. American Medical Trainee Perspectives on Ethical Conflicts during a Short-Term Global Health Rotation in Ethiopia: A Qualitative Analysis of 30 Cases. Am J Trop Med Hyg 2022; 106:398-411. [PMID: 34724634 PMCID: PMC8832937 DOI: 10.4269/ajtmh.21-0179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 09/09/2021] [Indexed: 02/03/2023] Open
Abstract
There has been a significant increase in the number of students, residents, and fellows from high-income settings participating in short-term global health experiences (STGHEs) during their medical training. This analysis explores a series of ethical conflicts reported by medical residents and fellows from Emory University School of Medicine in the United States who participated in a 1-month global health rotation in Ethiopia. A constant comparative analysis was conducted using 30 consecutive reflective essays to identify emerging categories and themes of ethical conflicts experienced by the trainees. Ethical conflicts were internal; based in the presence of the visiting trainee and their personal interactions; or external, occurring due to witnessed events. Themes within internal conflicts include issues around professional identity and insufficient preparation for the rotation. External experiences were further stratified by the trainee's perception that Ethiopian colleagues agreed that the scenario represented an ethical conflict (congruent) or disagreed with the visiting trainee's perspective (incongruent). Examples of congruent themes included recognizing opportunities for collaboration and witnessing ethical conflicts that are similar to those experienced in the United States. Incongruent themes included utilization of existing resources, issues surrounding informed consent, and differing expectations of clinical outcomes. By acknowledging the frequency and roots of ethical conflicts experienced during STGHEs, sponsors may better prepare visiting trainees and reframe these conflicts as collaborative educational experiences that benefit both the visiting trainee and host providers.
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Affiliation(s)
- Chelsea E. Modlin
- Department of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland;,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia;,Address correspondence to Chelsea Modlin, Johns Hopkins University School of Medicine, 1830 E. Monument St., #450B, Baltimore, MD 21205.
| | | | - Benjamin Stoff
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia;,Emory Center for Ethics, Atlanta, Georgia
| | - Dawn L. Comeau
- Emory University Rollins School of Public Health, Atlanta, Georgia;,Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Tewodros H. Gebremariam
- Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Miliard Derbew
- Department of Pediatric Surgery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta Georgia
| | - Carlos del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta Georgia
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta Georgia
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18
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Smith AGC, Gujabidze M, Avaliani T, Blumberg HM, Collins JM, Sabanadze S, Bakuradze T, Avaliani Z, Kempker RR, Kipiani M. Clinical outcomes among patients with tuberculous meningitis receiving intensified treatment regimens. Int J Tuberc Lung Dis 2021; 25:632-639. [PMID: 34330348 DOI: 10.5588/ijtld.21.0159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia.OBJECTIVE: To determine clinical outcomes of patients with tuberculous meningitis (TBM) treated with an intensified regimen including a fluoroquinolone (FQ) and an injectable agent.DESIGN: Prospective cohort of patients aged ≥16 years initiating treatment for TBM at the NCTLD from January 2018 to December 2019. Treatment outcomes and neurologic disability at 1, 6 and 12 months after treatment initiation were assessed.RESULTS: Among 77 patients with median follow-up time of 363 days (IQR 269-374), 97% received a FQ, 62% an injectable agent, 44% linezolid and 39% a carbapenem. Fifty-seven patients (74%) successfully completed treatment, 2 (2.6%) had treatment failure, 6 (7.8%) died, and the remainder (12%) were lost to follow up. Among 11 patients treated for multidrug-resistant TBM, the median follow-up time was 467 days and one patient (8%) died. Regarding neurologic outcomes, 14/76 (18%) patients had Modified Rankin Scores of 0 at baseline, improving to 85% (56/66) and 94% (47/50) at 6 and 12 months, respectively.CONCLUSION: Intensified multidrug treatment regimens including a FQ and an injectable agent in all patients and newly implemented drugs in patients with multidrug-resistant TBM resulted in low mortality and favorable neurologic outcomes.
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Affiliation(s)
- A G C Smith
- Emory University School of Medicine, Atlanta, GA, USA
| | - M Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - T Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - H M Blumberg
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, Departments of Epidemiology and Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - J M Collins
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - S Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - T Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - R R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - M Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, The University of Georgia, Tbilisi, Georgia
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19
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Vashakidze SA, Gogishvili SG, Nikolaishvili KG, Avaliani ZR, Chandrakumaran A, Gogishvili GS, Magee M, Blumberg HM, Kempker RR. Adjunctive surgery versus medical treatment among patients with cavitary multidrug-resistant tuberculosis. Eur J Cardiothorac Surg 2021; 60:1279-1285. [PMID: 34297819 DOI: 10.1093/ejcts/ezab337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 06/15/2021] [Accepted: 06/17/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Surgical resection is recommended as adjunctive treatment for multidrug-resistant (MDR) tuberculosis (TB) in certain scenarios; however, data are limited. We sought to evaluate the impact of surgery by comparing TB outcomes among patients with cavitary disease who received medical versus combined medical and surgical treatment. METHODS A cohort of all patients with cavitary MDR or extensively drug-resistant (XDR) TB treated in Tbilisi, Georgia, between 2008 and 2012. Patients meeting indications for surgery underwent adjunctive resection in addition to medical treatment. We compared TB outcomes (proportions achieving cure/complete) among patients who received adjunctive surgery to those who received medical treatment alone using an adjusted robust Poisson regression. RESULTS Among 408 patients, 299 received medical treatment alone and 109 combined medical and surgical treatment. Patients in the non-surgical group were older and had higher rates of tobacco and alcohol use and bilateral disease compared to the surgical group. Patients in the surgical group had higher rates of XDR disease (28% vs 15%). Favourable outcomes were higher among the surgical versus non-surgical group cohort (76% vs 41%). After adjusting for multiple factors, the association between adjunctive resection and favourable outcome remained (adjusted risk ratio 1.6, 95% confidence interval 1.3-2.0); the relationship was also observed in secondary models that excluded patients with bilateral disease (contraindication for surgery) and patients receiving <6 months of treatment. Major postoperative complications occurred among 8 patients (7%) with no postoperative mortality. CONCLUSIONS Adjunctive surgery is safe and may improve the effectiveness of treatment among select patients with cavitary MDR- and XDR-TB.
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Affiliation(s)
- Sergo A Vashakidze
- Thoracic Surgery Department, National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia.,The University of Georgia, Tbilisi, Georgia
| | - Shota G Gogishvili
- Thoracic Surgery Department, National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Ketino G Nikolaishvili
- Thoracic Surgery Department, National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza R Avaliani
- Thoracic Surgery Department, National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | | | - Giorgi Sh Gogishvili
- Thoracic Surgery Department, National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Mathew Magee
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia Emory University, Atlanta, GA, USA
| | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia Emory University, Atlanta, GA, USA
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20
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Graciaa DS, Kempker RR, Sanikidze E, Tukvadze S, Mikiashvili L, Aspindzelashvili R, Alkhazashvili D, Blumberg HM, Avaliani Z, Tukvadze N. TB research amidst the COVID-19 pandemic. Int J Tuberc Lung Dis 2021; 25:167-170. [PMID: 33688804 PMCID: PMC8105679 DOI: 10.5588/ijtld.20.0830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- D S Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - R R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - E Sanikidze
- Department of Medical Ethics and Law, David Tvildiani Medical University, Tbilisi, Georgia
| | - S Tukvadze
- Georgian American University, Tbilisi, Georgia
| | - L Mikiashvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | | | - D Alkhazashvili
- Community Advisory Board, National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - H M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Z Avaliani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - N Tukvadze
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
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21
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McLaughlin TA, Nizam A, Hayara FO, Ouma GS, Campbell A, Khayumbi J, Ongalo J, Ouma SG, Shah NS, Altman JD, Kaushal D, Rengarajan J, Ernst JD, Blumberg HM, Waller LA, Gandhi NR, Day CL, Benkeser D. Schistosoma mansoni Infection Is Associated With a Higher Probability of Tuberculosis Disease in HIV-Infected Adults in Kenya. J Acquir Immune Defic Syndr 2021; 86:157-163. [PMID: 33074856 PMCID: PMC8284023 DOI: 10.1097/qai.0000000000002536] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/28/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Helminth infections can modulate immunity to Mycobacterium tuberculosis (Mtb). However, the effect of helminths, including Schistosoma mansoni (SM), on Mtb infection outcomes is less clear. Furthermore, HIV is a known risk factor for tuberculosis (TB) disease and has been implicated in SM pathogenesis. Therefore, it is important to evaluate whether HIV modifies the association between SM and Mtb infection. SETTING HIV-infected and HIV-uninfected adults were enrolled in Kisumu County, Kenya, between 2014 and 2017 and categorized into 3 groups based on Mtb infection status: Mtb-uninfected healthy controls, latent TB infection (LTBI), and active TB disease. Participants were subsequently evaluated for infection with SM. METHODS We used targeted minimum loss estimation and super learning to estimate a covariate-adjusted association between SM and Mtb infection outcomes, defined as the probability of being Mtb-uninfected healthy controls, LTBI, or TB. HIV status was evaluated as an effect modifier of this association. RESULTS SM was not associated with differences in baseline demographic or clinical features of participants in this study, nor with additional parasitic infections. Covariate-adjusted analyses indicated that infection with SM was associated with a 4% higher estimated proportion of active TB cases in HIV-uninfected individuals and a 14% higher estimated proportion of active TB cases in HIV-infected individuals. There were no differences in estimated proportions of LTBI cases. CONCLUSIONS We provide evidence that SM infection is associated with a higher probability of active TB disease, particularly in HIV-infected individuals.
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Affiliation(s)
| | - Azhar Nizam
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | | | - Gregory Sadat Ouma
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Angela Campbell
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Jeremiah Khayumbi
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Joshua Ongalo
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Samuel Gurrion Ouma
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - N. Sarita Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - John D. Altman
- Emory Vaccine Center, Emory University, Atlanta, GA USA
- Department of Microbiology & Immunology, Emory University School of Medicine, Atlanta, GA USA
| | - Deepak Kaushal
- Southwest National Primate Research Center, Texas Biomedical Research Center, San Antonio, TX
| | - Jyothi Rengarajan
- Emory Vaccine Center, Emory University, Atlanta, GA USA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Joel D. Ernst
- Division of Experimental Medicine, Department of Medicine, University of California, San Francisco, CA USA
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Lance A. Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Neel R. Gandhi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Cheryl L. Day
- Emory Vaccine Center, Emory University, Atlanta, GA USA
- Department of Microbiology & Immunology, Emory University School of Medicine, Atlanta, GA USA
| | - David Benkeser
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA USA
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22
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Madzgharashvili T, Salindri AD, Magee MJ, Tukvadze N, Avaliani Z, Blumberg HM, Kempker RR, Lomtadze N. Treatment Outcomes Among Pediatric Patients With Highly Drug-Resistant Tuberculosis: The Role of New and Repurposed Second-Line Tuberculosis Drugs. J Pediatric Infect Dis Soc 2020; 10:457-467. [PMID: 33347564 PMCID: PMC8087132 DOI: 10.1093/jpids/piaa139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/04/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Among pediatric patients with multidrug-resistant tuberculosis (MDR-TB), limited data exist regarding treatment outcomes in the context of the new and repurposed second-line TB drugs (SLDs). We aimed to describe the treatment outcomes among pediatric MDR-TB patients receiving new and repurposed SLDs including the proportion who achieved favorable outcomes. METHODS We conducted a retrospective cohort study among pediatric patients (age ≤18 years) treated for MDR-TB in the country of Georgia from 2009 to 2016. A "new and repurposed" SLD regimen was defined as a regimen that included linezolid, bedaquiline, and/or delamanid. Favorable treatment outcome was defined by treatment completion or documented microbial "cure" status at the end of treatment. We assessed the association between the use of the new and repurposed SLDs with MDR-TB treatment outcomes using bivariate analyses and log-binomial regression. RESULTS There were 124 pediatric MDR-TB patients (median age: 13.7; interquartile range: 4.6-16.0) initiating treatment; 119 (96.0%) had a treatment outcome recorded and were included in our analyses. Eighteen (15.1%) patients received new and repurposed SLDs from 2015 or later. After adjusting for potential confounders, the proportion achieving favorable MDR-TB treatment outcomes was higher among patients treated with SLD regimens that included new and/or repurposed drugs when compared with those treated without (adjusted risk ratio: 1.17; 95% confidence interval: 0.51-2.72). CONCLUSIONS We observed a high proportion of favorable treatment outcomes among pediatric patients with MDR-TB receiving the new and repurposed SLDs. Further studies to evaluate the efficacy and children's tolerability of the new and repurposed SLDs are still warranted.
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Affiliation(s)
- Tea Madzgharashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia,Corresponding Author: Tea Madzgharashvili, MD, National Center for Tuberculosis and Lung Disease, 8 Achara Street, Tbilisi, Georgia. E-mail:
| | - Argita D Salindri
- Department of Population Health Sciences, Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - Matthew J Magee
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Henry M Blumberg
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA,Department of Medicine, Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Nino Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
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23
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Kempker RR, Mikiashvili L, Zhao Y, Benkeser D, Barbakadze K, Bablishvili N, Avaliani Z, Peloquin CA, Blumberg HM, Kipiani M. Clinical Outcomes Among Patients With Drug-resistant Tuberculosis Receiving Bedaquiline- or Delamanid-Containing Regimens. Clin Infect Dis 2020; 71:2336-2344. [PMID: 31712809 PMCID: PMC7713674 DOI: 10.1093/cid/ciz1107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/08/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Bedaquiline and delamanid are newly available drugs for treating multidrug-resistant tuberculosis (MDR-TB); however, there are limited data guiding their use and no comparison studies. METHODS We conducted a prospective, observational study among patients with MDR-TB in Georgia who were receiving a bedaquiline- or delamanid-based treatment regimen. Monthly sputum cultures, minimal inhibitory concentration testing, and adverse event monitoring were performed. Primary outcomes were culture conversion rates and clinical outcomes. Targeted maximum likelihood estimation and super learning were utilized to produce a covariate-adjusted proportion of outcomes for each regimen. RESULTS Among 156 patients with MDR-TB, 100 were enrolled and 95 were receiving a bedaquiline-based (n = 64) or delamanid-based (n = 31) regimen. Most were male (82%) and the median age was 38 years. Rates of previous treatment (56%) and cavitary disease (61%) were high. The most common companion drugs included linezolid, clofazimine, cycloserine, and a fluoroquinolone. The median numbers of effective drugs received among patients on bedaquiline-based (4; interquartile range [IQR], 4-4) and delamanid-based (4; IQR, 3.5-5) regimens were similar. Rates of acquired drug resistance were significantly higher among patients receiving delamanid versus bedaquiline (36% vs 10%, respectively; P < .01). Adjusted rates of sputum culture conversion at 2 months (67% vs 47%, respectively; P = .10) and 6 months (95% vs 74%, respectively; P < .01), as well as more favorable clinical outcomes (96% vs 72%, respectively; P < .01), were higher among patients receiving bedaquiline versus delamanid. CONCLUSIONS Among patients with MDR-TB, bedaquiline-based regimens were associated with higher rates of sputum culture conversion, more favorable outcomes, and a lower rate of acquired drug resistance versus delamanid-based regimens.
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Affiliation(s)
- R R Kempker
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - L Mikiashvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Y Zhao
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - D Benkeser
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - K Barbakadze
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - N Bablishvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - C A Peloquin
- Department of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - H M Blumberg
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
- Departments of Epidemiology and Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - M Kipiani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
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24
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Collins JM, Stout JE, Ayers T, Hill AN, Katz DJ, Ho CS, Blumberg HM, Winglee K. Prevalence of Latent Tuberculosis Infection among Non-U.S.-Born Persons by Country of Birth - United States, 2012-2017. Clin Infect Dis 2020; 73:e3468-e3475. [PMID: 33137172 DOI: 10.1093/cid/ciaa1662] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Most tuberculosis (TB) disease in the U.S. is attributed to reactivation of remotely acquired latent TB infection (LTBI) in non-U.S.-born persons who were likely infected with Mycobacterium tuberculosis in their countries of birth. Information on LTBI prevalence by country of birth could help guide local providers and health departments to scale up the LTBI screening and preventive treatment needed to advance progress towards TB elimination. METHODS 13 805 non-U.S.-born persons at high risk of TB infection or progression to TB disease were screened for LTBI at 16 clinical sites located across the United States with a tuberculin skin test, QuantiFERON ® Gold In-Tube test, and T-SPOT ®.TB test. Bayesian latent class analysis was applied to test results to estimate LTBI prevalence and associated credible intervals (CRI) for each country or world region of birth. RESULTS Among the study population, the estimated LTBI prevalence was 31% (95% CRI 26% - 35%). Country-of-birth-level LTBI prevalence estimates were highest for persons born in Haiti, Peru, Somalia, Ethiopia, Vietnam, and Bhutan, ranging from 42%-55%. LTBI prevalence estimates were lowest for persons born in Colombia, Malaysia, and Thailand, ranging from 8%-13%. CONCLUSIONS LTBI prevalence in persons born outside the United States varies widely by country. These estimates can help target community outreach efforts to the highest risk groups.
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Affiliation(s)
- Jeffrey M Collins
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Tracy Ayers
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Andrew N Hill
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Dolly J Katz
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christine S Ho
- India Country Office, U.S. Centers for Disease Control and Prevention, New Delhi, India
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.,Department of Epidemiology and Global Health, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Kathryn Winglee
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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25
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Collins JM, Siddiqa A, Jones DP, Liu K, Kempker RR, Nizam A, Shah NS, Ismail N, Ouma SG, Tukvadze N, Li S, Day CL, Rengarajan J, Brust JC, Gandhi NR, Ernst JD, Blumberg HM, Ziegler TR. Tryptophan catabolism reflects disease activity in human tuberculosis. JCI Insight 2020; 5:137131. [PMID: 32369456 DOI: 10.1172/jci.insight.137131] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/22/2020] [Indexed: 12/26/2022] Open
Abstract
There is limited understanding of the role of host metabolism in the pathophysiology of human tuberculosis (TB). Using high-resolution metabolomics with an unbiased approach to metabolic pathway analysis, we discovered that the tryptophan pathway is highly regulated throughout the spectrum of TB infection and disease. This regulation is characterized by increased catabolism of tryptophan to kynurenine, which was evident not only in active TB disease but also in latent TB infection (LTBI). Further, we found that tryptophan catabolism is reversed with effective treatment of both active TB disease and LTBI in a manner commensurate with bacterial clearance. Persons with active TB and LTBI also exhibited increased expression of indoleamine 2,3-dioxygenase-1 (IDO-1), suggesting IDO-1 mediates observed increases in tryptophan catabolism. Together, these data indicate IDO-1-mediated tryptophan catabolism is highly preserved in the human response to Mycobacterium tuberculosis and could be a target for biomarker development as well as host-directed therapies.
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Affiliation(s)
- Jeffrey M Collins
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amnah Siddiqa
- Jackson Laboratory for Genomic Medicine, Farmington, Connecticut, USA
| | - Dean P Jones
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ken Liu
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Azhar Nizam
- Department of Biostatistics and Bioinformatics
| | - N Sarita Shah
- Department of Epidemiology, and.,Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Nazir Ismail
- Centre for Tuberculosis, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa.,Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa.,Department of Internal Medicine, University of Witwatersrand, Johannesburg, South Africa
| | | | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shuzhao Li
- Jackson Laboratory for Genomic Medicine, Farmington, Connecticut, USA
| | - Cheryl L Day
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia, USA.,Emory Vaccine Center and.,Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, USA
| | - Jyothi Rengarajan
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Emory Vaccine Center and.,Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, USA
| | - James Cm Brust
- Division of General Internal Medicine and.,Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Neel R Gandhi
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, and.,Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Joel D Ernst
- Division of Experimental Medicine, Department of Medicine, UCSF School of Medicine, San Francisco, California, USA
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, and.,Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA.,Emory Vaccine Center and
| | - Thomas R Ziegler
- Division of Endocrinology, Metabolism, and Lipids and.,Emory Center for Clinical and Molecular Nutrition, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Section of Endocrinology, Atlanta Veterans Affairs Medical Center, Atlanta Georgia, USA
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Foreman TW, Bucşan AN, Mehra S, Peloquin C, Doyle LA, Russell-Lodrigue K, Gandhi NR, Altman J, Day CL, Ernst JD, Blumberg HM, Rengarajan J, Kaushal D. Isoniazid and Rifapentine Treatment Eradicates Persistent Mycobacterium tuberculosis in Macaques. Am J Respir Crit Care Med 2020; 201:469-477. [PMID: 31647877 DOI: 10.1164/rccm.201903-0646oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
EXPRESSION OF CONCERN: The authors have informed the Journal that they have become aware that some of the data in this article may be unreliable. Therefore, we have added this expression of concern while the situation is being reviewed. Rationale: Direct evidence for persistence of Mycobacterium tuberculosis (Mtb) during asymptomatic latent tuberculosis infection (LTBI) in humans is currently lacking. Moreover, although a 12-week regimen of once-weekly isoniazid and rifapentine (3HP) is currently recommended by the CDC as treatment for LTBI, experimental evidence for 3HP-mediated clearance of persistent Mtb infection in human lungs has not been established.Objectives: Using a nonhuman primate (NHP) model of TB, we sought to assess 3HP treatment-mediated clearance of Mtb infection in latently infected macaques.Methods: Sixteen NHPs were infected via inhalation with ∼10 cfu of Mtb CDC1551, after which asymptomatic animals were either treated with 3HP or left untreated. Pharmacokinetics of the 3HP regimen were measured. Following treatment, animals were coinfected with simian immunodeficiency virus to assess reactivation of LTBI and development of active TB disease.Measurements and Main Results: Fourteen NHPs remained free of clinical signs or microbiological evidence of active TB following infection with Mtb and were subsequently either treated with 3HP (n = 7) or left untreated (n = 7). Untreated NHPs were asymptomatic for 7 months but harbored persistent Mtb infection, as shown by reactivation of latent infection following simian immunodeficiency virus coinfection. However, none of the treated animals developed TB reactivation disease, and they remained without clinical or microbiological evidence of persistent bacilli, suggesting treatment-mediated clearance of bacteria.Conclusions: Mtb can persist in asymptomatic macaques for at least 7 months. Furthermore, 3HP treatment effectively cleared bacteria and prevented reactivation of TB in latently infected macaques.
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Affiliation(s)
- Taylor W Foreman
- Tulane National Primate Research Center, Tulane University School of Medicine, Covington, Louisiana
| | - Allison N Bucşan
- Tulane National Primate Research Center, Tulane University School of Medicine, Covington, Louisiana
| | - Smriti Mehra
- Tulane National Primate Research Center, Tulane University School of Medicine, Covington, Louisiana
| | | | - Lara A Doyle
- Tulane National Primate Research Center, Tulane University School of Medicine, Covington, Louisiana
| | - Kasi Russell-Lodrigue
- Tulane National Primate Research Center, Tulane University School of Medicine, Covington, Louisiana
| | | | - John Altman
- Emory Vaccine Center and Yerkes National Primate Center, Emory University, Atlanta, Georgia.,Department of Microbiology and Immunology and
| | - Cheryl L Day
- Emory Vaccine Center and Yerkes National Primate Center, Emory University, Atlanta, Georgia.,Department of Microbiology and Immunology and
| | - Joel D Ernst
- Division of Experimental Medicine, Department of Medicine, University of California, San Francisco, California; and
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jyothi Rengarajan
- Emory Vaccine Center and Yerkes National Primate Center, Emory University, Atlanta, Georgia.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Deepak Kaushal
- Tulane National Primate Research Center, Tulane University School of Medicine, Covington, Louisiana.,Southwest National Primate Research Center, Texas Biomedical Research Center, San Antonio, Texas
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Manyazewal T, Woldeamanuel Y, Holland DP, Fekadu A, Blumberg HM, Marconi VC. Electronic pillbox-enabled self-administered therapy versus standard directly observed therapy for tuberculosis medication adherence and treatment outcomes in Ethiopia (SELFTB): protocol for a multicenter randomized controlled trial. Trials 2020; 21:383. [PMID: 32370774 PMCID: PMC7201596 DOI: 10.1186/s13063-020-04324-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/10/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To address the multifaceted challenges associated with tuberculosis (TB) in-person directly observed therapy (DOT), the World Health Organization recently recommended that countries maximize the use of digital adherence technologies. Sub-Saharan Africa needs to investigate the effectiveness of such technologies in local contexts and proactively contribute to global decisions around patient-centered TB care. This study aims to evaluate the effectiveness of pillbox-enabled self-administered therapy (SAT) compared to standard DOT on adherence to TB medication and treatment outcomes in Ethiopia. It also aims to assess the usability, acceptability, and cost-effectiveness of the intervention from the patient and provider perspectives. METHODS This is a multicenter, randomized, controlled, open-label, superiority, effectiveness-implementation hybrid, mixed-methods, two-arm trial. The study is designed to enroll 144 outpatients with new or previously treated, bacteriologically confirmed, drug-sensitive pulmonary TB who are eligible to start the standard 6-month first-line anti-TB regimen. Participants in the intervention arm (n = 72) will receive 15 days of HRZE-isoniazid, rifampicin, pyrazinamide, and ethambutol-fixed-dose combination therapy in the evriMED500 medication event reminder monitor device for self-administration. When returned, providers will count any remaining tablets in the device, download the pill-taking data, and refill based on preset criteria. Participants can consult the provider in cases of illness or adverse events outside of scheduled visits. Providers will handle participants in the control arm (n = 72) according to the standard in-person DOT. Both arms will be followed up throughout the 2-month intensive phase. The primary outcomes will be medication adherence and sputum conversion. Adherence to medication will be calculated as the proportion of patients who missed doses in the intervention (pill count) versus DOT (direct observation) arms, confirmed further by IsoScreen urine isoniazid test and a self-report of adherence on eight-item Morisky Medication Adherence Scale. Sputum conversion is defined as the proportion of patients with smear conversion following the intensive phase in intervention versus DOT arms, confirmed further by pre-post intensive phase BACTEC MGIT TB liquid culture. Pre-post treatment MGIT drug susceptibility testing will determine whether resistance to anti-TB drugs could have impacted culture conversion. Secondary outcomes will include other clinical outcomes (treatment not completed, death, or loss to follow-up), cost-effectiveness-individual and societal costs with quality-adjusted life years-and acceptability and usability of the intervention by patients and providers. DISCUSSION This study will be the first in Ethiopia, and of the first three in sub-Saharan Africa, to determine whether electronic pillbox-enabled SAT improves adherence to TB medication and treatment outcomes, all without affecting the inherent dignity and economic wellbeing of patients with TB. TRIAL REGISTRATION ClinicalTrials.gov, NCT04216420. Registered on 2 January 2020.
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Affiliation(s)
- Tsegahun Manyazewal
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Yimtubezinash Woldeamanuel
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa, P.O. Box 9086, Addis Ababa, Ethiopia
| | - David P. Holland
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA 30322 USA
| | - Abebaw Fekadu
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Henry M. Blumberg
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA 30322 USA
| | - Vincent C. Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA 30322 USA
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Collins JM, Blumberg HM. The blueprint for prevention of nosocomial tuberculosis transmission is clear, but why don't we have the will to follow it? Clin Microbiol Infect 2020; 26:970-972. [PMID: 32360777 DOI: 10.1016/j.cmi.2020.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/18/2022]
Affiliation(s)
- J M Collins
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - H M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Department of Epidemiology and Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, GA, USA.
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29
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Buziashvili M, Mirtskhulava V, Kipiani M, Blumberg HM, Baliashvili D, Magee MJ, Furin JJ, Tukvadze N, Kempker RR. Rates and risk factors for nephrotoxicity and ototoxicity among tuberculosis patients in Tbilisi, Georgia. Int J Tuberc Lung Dis 2020; 23:1005-1011. [PMID: 31615608 DOI: 10.5588/ijtld.18.0626] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Treatment of multidrug-resistant tuberculosis (MDR-TB) is lengthy and utilizes second-line anti-TB drugs associated with frequent adverse drug reactions (ADRs).OBJECTIVE: To evaluate the prevalence of and risk factors for ADRs among patients with MDR- and extensively drug-resistant TB (XDR-TB).DESIGN: A retrospective chart review of patients initiating treatment for M/XDR-TB in 2010-2012 in Tbilisi, Georgia.RESULTS: Eighty (54%) and 38 (26%) of 147 patients developed nephrotoxicity per RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) classification and ototoxicity, respectively. Twenty-five (17%) patients required permanent interruption of injectables due to an ADR. Median hospital stay, total treatment duration and number of regimen changes were higher among those with nephrotoxicity and/or ototoxicity, compared to those without (P < 0.01). Multinomial logistic regression analysis identified increasing age (per year) as a risk factor for nephrotoxicity (aOR 1.08, 95%CI 1.03-1.12) and for both, nephro- and ototoxicity (aOR 1.11, 95%CI 1.05-1.17). Low baseline creatinine clearance (CrCl) was a significant risk factor for developing nephrotoxicity (aOR 1.05, 95%CI 1.02-1.07).CONCLUSION: Second-line injectable drug-related ADRs are common among M/XDR-TB patients. Patients with increasing age and low baseline CrCl should be monitored closely for injectable-related ADRs. Notably, our findings support WHO's latest recommendations on introduction of injectable free anti-TB treatment regimens.
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Affiliation(s)
- M Buziashvili
- Department of Scientific Research, National Center for Tuberculosis and Lung Diseases, Tbilisi
| | | | - M Kipiani
- Department of Scientific Research, National Center for Tuberculosis and Lung Diseases, Tbilisi
| | - H M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA, Department of Epidemiology and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - D Baliashvili
- Department of Epidemiology and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, Department of Infectious Diseases, National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - M J Magee
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, GA
| | - J J Furin
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - N Tukvadze
- Department of Scientific Research, National Center for Tuberculosis and Lung Diseases, Tbilisi
| | - R R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA
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30
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Getahun M, Blumberg HM, Sinshaw W, Diriba G, Mollalign H, Tesfaye E, Yenew B, Taddess M, Zewdie A, Dagne K, Beyene D, Kempker RR, Ameni G. Low Prevalence of Mycobacterium bovis in Tuberculosis Patients, Ethiopia. Emerg Infect Dis 2020; 26:613-615. [PMID: 32091379 PMCID: PMC7045829 DOI: 10.3201/eid2603.190473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
An estimated 17% of all tuberculosis cases in Ethiopia are caused by Mycobacterium bovis. We used M. tuberculosis complex isolates to identify the prevalence of M. bovis as the cause of pulmonary tuberculosis. Our findings indicate that the proportion of pulmonary tuberculosis due to M. bovis is small (0.12%).
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Kelly CM, Vins H, Spicer JO, Mengistu BS, Wilson DR, Derbew M, Bekele A, Mariam DH, del Rio C, Kempker RR, Comeau DL, Blumberg HM. The rapid scale up of medical education in Ethiopia: Medical student experiences and the role of e-learning at Addis Ababa University. PLoS One 2019; 14:e0221989. [PMID: 31487332 PMCID: PMC6728036 DOI: 10.1371/journal.pone.0221989] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 08/20/2019] [Indexed: 11/18/2022] Open
Abstract
Background In response to a physician shortage in Ethiopia, the number of medical students admitted to public universities was rapidly increased through a “flooding” policy. Objectives To assess medical student perceptions on the impact of the “flooding” policy on medical education and e-learning initiatives, as well as plans for future emigration. Design A cross-sectional survey of medical students at AAU was implemented in 2014. Attitude and practice items were assessed using a Likert scale. Logistic regression analysis was performed to identify characteristics associated with an interest in future emigration. Results 673 (99.6%) of 676 students approached completed the survey, representing 39.5% of all 1705 medical students enrolled at AAU in 2014. Most students felt the “flooding” policy had a negative impact on their medical education and >90% felt there was not adequate infrastructure to support the increased student body. E-learning activities to accommodate increased class size included distribution of electronic tablets, but at the time of the survey only 34.8% of students still had a working tablet and 82.3% reported problems with internet connectivity. Most preclinical students (85.1%) who had attended live-streamed lectures preferred traditional classroom lectures. Half of the students (49.5%) intended to practice medicine in Ethiopia. Independent risk factors for planning to emigrate included age <21 years (aOR = 1.30, 95% CI 1.04, 1.97); having applied to medical school for reasons other than “wanting to be a physician” (aOR = 1.55, 95% CI 1.14, 2.20), and not believing that “flooding” policy would increase the number of physicians working in Ethiopia (aOR = 1.87, 95% CI 1.33, 2.58). Conclusions The “flooding” policy lead to significant educational challenges that were not fully alleviated by e-learning initiatives. Concomitant increases in resources for infrastructure development and faculty expansion are needed to maintain quality medical education. Additional research is needed on factors that influence medical graduates decision to emigrate.
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Affiliation(s)
- Caitrin M. Kelly
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
- * E-mail:
| | - Holly Vins
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health of Emory University, Atlanta, GA, United States of America
| | - Jennifer O. Spicer
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Brittney S. Mengistu
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health of Emory University, Atlanta, GA, United States of America
| | - Daphne R. Wilson
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health of Emory University, Atlanta, GA, United States of America
- School of Law, Emory University, Atlanta, GA, United States of America
| | - Miliard Derbew
- Department of Surgery, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia
| | - Abebe Bekele
- Department of Surgery, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia
| | - Damen Haile Mariam
- Department of Community Health, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Carlos del Rio
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
- Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, GA, United States of America
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Dawn L. Comeau
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health of Emory University, Atlanta, GA, United States of America
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
- Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, GA, United States of America
- Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, GA, United States of America
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Merid Y, Woldeamanuel Y, Abebe M, Datiko DG, Hailu T, Habtamu G, Assefa G, Kempker RR, Blumberg HM, Aseffa A. High utility of active tuberculosis case finding in an Ethiopian prison. Int J Tuberc Lung Dis 2019; 22:524-529. [PMID: 29663957 DOI: 10.5588/ijtld.17.0635] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Hawassa Prison, Southern Region of Ethiopia. OBJECTIVE To determine the burden of pulmonary tuberculosis (TB) using active case finding among prisoners. DESIGN In this cross-sectional study, prisoners were screened for TB using a symptom screen. Those with cough of 2 weeks had spot and morning sputum samples collected for acid-fast bacilli (AFB) smear microscopy and molecular diagnostic testing (Xpert® MTB/RIF). RESULTS Among 2068 prisoners, 372 (18%) had a positive cough screen. The median age of these 372 persons was 23 years, 97% were male and 63% were from urban areas. Among those with a positive symptom screen, 8 (2%) were AFB sputum smear-positive and 31 (8%) were Xpert-positive. The point prevalence of pulmonary TB at the prison was 1748 per 100 000 persons. In multivariate analysis, persons with cough >4 weeks were more likely to have TB (OR 3.34, 95%CI 1.54-7.23). CONCLUSION A high prevalence of TB was detected among inmates at a large Ethiopian prison. Active case finding using a cough symptom screen in combination with Xpert had high utility, and has the potential to interrupt transmission of Mycobacterium tuberculosis in correctional facilities in low- and middle-income, high-burden countries.
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Affiliation(s)
- Y Merid
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia; Addis Ababa University, Addis Ababa, Hawassa University, Hawassa, Ethiopia
| | | | - M Abebe
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - D G Datiko
- REACH Ethiopia, Hawassa, Ethiopia, Liverpool School of Tropical Medicine, Liverpool, UK
| | - T Hailu
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - G Habtamu
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - G Assefa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - R R Kempker
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - H M Blumberg
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - A Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
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Kempker RR, Chkhartishvili N, Kinkladze I, Schechter MC, Harrington K, Rukhadze N, Dzigua L, Tserstvadze T, Del Rio C, Blumberg HM, Tukvadze N. High Yield of Active Tuberculosis Case Finding Among HIV-Infected Patients Using Xpert MTB/RIF Testing. Open Forum Infect Dis 2019; 6:ofz233. [PMID: 31211163 PMCID: PMC6559269 DOI: 10.1093/ofid/ofz233] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/16/2019] [Indexed: 12/23/2022] Open
Abstract
Objective Conduct an active case finding study in Tbilisi, Georgia, for pulmonary tuberculosis (TB) among people living with HIV (PLWH). Methods Newly diagnosed HIV patients were assessed for symptoms and asked to submit sputum samples for smear microscopy, culture, and molecular diagnostic testing (Xpert MTB/RIF). Results Among 276 PLWH, 131 agreed to participate and 103 submitted sputum samples. Most participants were male (70%) and mean age of 43 years. There were high rates of a positive hepatitis C virus (HCV) antibody test (46%) and the median CD4 count was 122 cells/mm3. A total of 15 (11.5%) persons were diagnosed with pulmonary TB, including 1 each with multidrug-resistant and isoniazid-resistant disease. Twelve had a positive culture for Mycobacterium tuberculosis and Xpert TB/RIF assay, and 4 had positive smear microscopy. Patients with pulmonary TB were more likely to use injection drugs (67% vs 36%, P = .02) and have a positive HCV antibody (73% vs 42%, P = .02). The presence and absence of any TB symptom had a sensitivity and negative predictive value for TB of 93% and 98%, respectively. Conclusion Our findings highlight the high prevalence of TB among newly diagnosed HIV-infected patients in an area with high rates of drug-resistant TB and the utility of an active case finding strategy for TB diagnosis.
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Affiliation(s)
- Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Inga Kinkladze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Marcos C Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Nino Rukhadze
- Infectious Diseases, AIDS, and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Lela Dzigua
- Infectious Diseases, AIDS, and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Tengiz Tserstvadze
- Infectious Diseases, AIDS, and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
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Frank M, Adamashvili N, Lomtadze N, Kokhreidze E, Avaliani Z, Kempker RR, Blumberg HM. Long-term Follow-up Reveals High Posttreatment Mortality Rate Among Patients With Extensively Drug-Resistant Tuberculosis in the Country of Georgia. Open Forum Infect Dis 2019; 6:ofz152. [PMID: 31041349 PMCID: PMC6483133 DOI: 10.1093/ofid/ofz152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 03/21/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Given very limited data, we assessed the long-term outcomes among patients with extensively drug-resistant (XDR) tuberculosis (TB). METHODS A retrospective population-based cohort study was performed in patients with XDR-TB diagnosed during 2011-2013 in the country of Georgia. Data were abstracted from the National TB Program, medical charts, interviews, and the national Georgian death registry. RESULTS Among 111 patients starting treatment for XDR-TB, 59 (53.2%) had newly diagnosed tuberculosis, and 3 (2.9%) had human immunodeficiency virus (HIV) coinfection. The median length of follow-up from diagnosis of XDR-TB to death or the end of study was 53.9 months (interquartile range, 27.2-66.3 months). End-of-treatment outcomes were available for 106 patients; 35 (33.0%) had a favorable outcome, and 71 (67.0%) had an unfavorable outcome, including death in 16 (15.1%). An additional 20 patients died after cessation of initial treatment, increasing the overall mortality rate to 34.0%. In multivariable analysis, an unfavorable initial end-of-treatment outcome was associated with posttreatment death (adjusted odds ratio, 14.41; 95% confidence interval, 1.78-117.13). CONCLUSIONS The overall mortality rate and specifically the posttreatment mortality rate were high among patients with XDR-TB. Patients with an unfavorable end-of-treatment outcome had an increased risk of death during follow-up. Our findings highlight the need for improved adherence, better-tolerated and shorter therapies, and enhanced posttreatment surveillance among patients treated for XDR-TB.
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Affiliation(s)
- Melanie Frank
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Nino Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Eka Kokhreidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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35
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Wischmeyer PE, Mintz-Cole RA, Baird CH, Easley KA, May AK, Sax HC, Kudsk KA, Hao L, Tran PH, Jones DP, Blumberg HM, Ziegler TR. Role of heat shock protein and cytokine expression as markers of clinical outcomes with glutamine-supplemented parenteral nutrition in surgical ICU patients. Clin Nutr 2019; 39:563-573. [PMID: 30981628 DOI: 10.1016/j.clnu.2019.02.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/26/2019] [Accepted: 02/26/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Nutrients, such as glutamine (GLN), have been shown to effect levels of a family of protective proteins termed heat shock proteins (HSPs) in experimental and clinical critical illness. HSPs are believed to serve as extracellular inflammatory messengers and intracellular cytoprotective molecules. Extracellular HSP70 (eHSP70) has been termed a chaperokine due to ability to modulate the immune response. Altered levels of eHSP70 are associated with various disease states. Larger clinical trial data on GLN effect on eHSP expression and eHSP70's association with inflammatory mediators and clinical outcomes in critical illness are limited. OBJECTIVE Explore effect of longitudinal change in serum eHSP70, eHSP27 and inflammatory cytokine levels on clinical outcomes such as pneumonia and mortality in adult surgical intensive care unit (SICU) patients. Further, evaluate effect of parenteral nutrition (PN) supplemented with GLN (GLN-PN) versus GLN-free, standard PN (STD-PN) on serum eHSP70 and eHSP27 concentrations. METHODS Secondary observational analysis of a multicenter clinical trial in 150 adults after cardiac, vascular, or gastrointestinal surgery requiring PN support and SICU care conducted at five academic medical centers. Patients received isocaloric, isonitrogenous PN, with or without GLN dipeptide. Serum eHSP70 and eHSP27, interleukin-6 (IL-6), and 8 (IL-8) concentrations were analyzed in patient serum at baseline (prior to study PN) and over 28 days of follow up. RESULTS eHSP70 declined over time in survivors during 28 days follow-up, but non-survivors had significantly higher eHSP70 concentrations compared to survivors. In patients developing pneumonia, eHSP70, eHSP27, IL-8, and IL-6 were significantly elevated. Adjusted relative risk for hospital mortality was reduced 75% (RR = 0.25, p = 0.001) for SICU patients with a faster decline in eHSP70. The area under the receiver operating characteristic curve was 0.85 (95% CI: 0.76 to 0.94) for the final model suggesting excellent discrimination between SICU survivors and non-survivors. GLN-PN did not alter eHSP70 or eHSP27 serum concentrations over time compared to STD-PN. CONCLUSION Our results suggest that serum HSP70 concentration may be an important marker for severity of illness and likelihood of recovery in the SICU. GLN-supplemented-PN did not increase eHSP70.
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Affiliation(s)
- Paul E Wischmeyer
- Duke University Hospital, Department of Anesthesiology and Duke Clinical Research Institute, 2301 Erwin Rd, Durham, NC 27710, USA.
| | - Rachael A Mintz-Cole
- Duke University Hospital, Department of Anesthesiology and Duke Clinical Research Institute, 2301 Erwin Rd, Durham, NC 27710, USA.
| | - Christine H Baird
- University of Colorado Denver Anschutz Medical Campus, Anesthesiology, 12700 E. 19th Avenue Box 8602, Aurora, CO 80045, USA.
| | - Kirk A Easley
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
| | - Addison K May
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37240, USA.
| | - Harry C Sax
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA.
| | - Kenneth A Kudsk
- Department of Surgery, University of Wisconsin, Schools of Medicine and Public Health, Madison, Madison, WI 53792, USA.
| | - Li Hao
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Phong H Tran
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Dean P Jones
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA; Center for Clinical and Molecular Nutrition, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
| | - Thomas R Ziegler
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA; Center for Clinical and Molecular Nutrition, Emory University School of Medicine, Atlanta, GA 30322, USA; Atlanta Veterans Affairs Medical Center, Decatur, GA 30033, USA.
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36
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Kempker RR, Blumberg HM. Global Health and the Infectious Diseases Physician-Scientist Workforce. J Infect Dis 2019; 219:1007-1008. [PMID: 30299486 PMCID: PMC6386802 DOI: 10.1093/infdis/jiy593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/04/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Departments of Epidemiology and Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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37
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Heinrichs MT, Vashakidze S, Nikolaishvili K, Sabulua I, Tukvadze N, Bablishvili N, Gogishvili S, Little BP, Bernheim A, Guarner J, Peloquin CA, Blumberg HM, Derendorf H, Kempker RR. Moxifloxacin target site concentrations in patients with pulmonary TB utilizing microdialysis: a clinical pharmacokinetic study. J Antimicrob Chemother 2019; 73:477-483. [PMID: 29186509 DOI: 10.1093/jac/dkx421] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/17/2017] [Indexed: 11/14/2022] Open
Abstract
Background Moxifloxacin is a second-line anti-TB drug that is useful in the treatment of drug-resistant TB. However, little is known about its target site pharmacokinetics. Lower drug concentrations at the infection site (i.e. in severe lung lesions including cavitary lesions) may lead to development and amplification of drug resistance. Improved knowledge regarding tissue penetration of anti-TB drugs will help guide drug development and optimize drug dosing. Methods Patients with culture-confirmed drug-resistant pulmonary TB scheduled to undergo adjunctive surgical lung resection were enrolled in Tbilisi, Georgia. Five serum samples per patient were collected at different timepoints including at the time of surgical resection (approximately at Tmax). Microdialysis was performed in the ex vivo tissue immediately after resection. Non-compartmental analysis was performed and a tissue/serum concentration ratio was calculated. Results Among the seven patients enrolled, the median moxifloxacin dose given was 7.7 mg/kg, the median age was 25.2 years, 57% were male and the median creatinine clearance was 95.4 mL/min. Most patients (71%) had suboptimal steady-state serum Cmax (total drug) concentrations. The median free moxifloxacin serum concentration at time of surgical resection was 1.23 μg/mL (range = 0.12-1.80) and the median free lung tissue concentration was 3.37 μg/mL (range = 0.81-5.76). The median free-tissue/free-serum concentration ratio was 3.20 (range = 0.66-28.08). Conclusions Moxifloxacin showed excellent penetration into diseased lung tissue (including cavitary lesions) among patients with pulmonary TB. Moxifloxacin lung tissue concentrations were higher than those seen in serum. Our findings highlight the importance of moxifloxacin in the treatment of MDR-TB and potentially any patient with pulmonary TB and severe lung lesions.
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Affiliation(s)
| | - Sergo Vashakidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | | | - Irina Sabulua
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Nino Bablishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shota Gogishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Brent P Little
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Adam Bernheim
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeannette Guarner
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Henry M Blumberg
- Division of Infectious Diseases Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.,Departments of Epidemiology and Global Health, Emory Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Russell R Kempker
- Division of Infectious Diseases Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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38
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Bizune DJ, Kempker RR, Kagei M, Yamin A, Mohamed O, Holland DP, Oladele A, Wang YF, Rebolledo PA, Blumberg HM, Ray SM, Schechter MC. Treatment Complexities Among Patients with Tuberculosis in a High HIV Prevalence Cohort in the United States. AIDS Res Hum Retroviruses 2018; 34:1050-1057. [PMID: 30105915 DOI: 10.1089/aid.2018.0126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The association between human immunodeficiency virus (HIV) infection and tuberculosis (TB) mortality has been studied extensively, but the impact of HIV on other clinically relevant aspects of TB care such as TB drug-related adverse events (AEs), hospital readmissions, and TB treatment duration is less well characterized. We describe the association of HIV infection with TB clinical complexities and outcomes in a high HIV prevalence cohort in the United States. This is a retrospective cohort study among patients treated for culture-confirmed TB between 2008 and 2015 at an inner-city hospital in Atlanta, GA. Univariate analysis was used to estimate association of HIV with TB treatment interruption due to AEs, hospital readmissions, and treatment duration. Final unfavorable TB treatment outcome was defined as death, loss to follow-up, or recurrent TB. Logistic regression modeling was used to estimate association of HIV with final unfavorable outcomes. Among 274 patients with TB, 96 (35%) had HIV coinfection. HIV-positive patients had more TB treatment interruptions due to AE (34% vs. 15%), were more likely to have a hospital readmission (50% vs. 21%), and received longer TB treatment (9.9 months vs. 8.8 months) compared to HIV-negative patients (p < .01 for all). HIV infection was not associated with final unfavorable outcomes in univariate [odds ratio (OR) = 1.86; confidence interval (95% CI) 0.99-3.49] or multivariate analysis (aOR = 1.13; 95% CI 0.52-2.39) (p ≥ .05 for both). While HIV infection was not associated with final unfavorable TB outcomes, TB/HIV coinfected patients had more complex treatment course underscoring the importance of maintaining resources and expertise to treat coinfected patients in our and similar settings.
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Affiliation(s)
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Aliya Yamin
- Communicable Disease Prevention Branch, Fulton County Board of Health, Atlanta, Georgia
| | - Omar Mohamed
- Communicable Disease Prevention Branch, Fulton County Board of Health, Atlanta, Georgia
| | - David P. Holland
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Communicable Disease Prevention Branch, Fulton County Board of Health, Atlanta, Georgia
| | | | - Yun F. Wang
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
- Department of Pathology, Grady Memorial Hospital, Atlanta, Georgia
| | - Paulina A. Rebolledo
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Henry M. Blumberg
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Susan M. Ray
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Marcos C. Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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39
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Collins JM, Walker DI, Jones DP, Tukvadze N, Liu KH, Tran VT, Uppal K, Frediani JK, Easley KA, Shenvi N, Khadka M, Ortlund EA, Kempker RR, Blumberg HM, Ziegler TR. High-resolution plasma metabolomics analysis to detect Mycobacterium tuberculosis-associated metabolites that distinguish active pulmonary tuberculosis in humans. PLoS One 2018; 13:e0205398. [PMID: 30308073 PMCID: PMC6181350 DOI: 10.1371/journal.pone.0205398] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 09/25/2018] [Indexed: 12/01/2022] Open
Abstract
Introduction Pulmonary tuberculosis (TB) is a major worldwide health problem that lacks robust blood-based biomarkers for detection of active disease. High-resolution metabolomics (HRM) is an innovative method to discover low-abundance metabolites as putative blood biomarkers to detect TB disease, including those known to be produced by the causative organism, Mycobacterium tuberculosis (Mtb). Methods We used HRM profiling to measure the plasma metabolome for 17 adults with active pulmonary TB disease and 16 of their household contacts without active TB. We used a suspect screening approach to identify metabolites previously described in cell culture studies of Mtb based on retention time and accurate mass matches. Results The association of relative metabolite abundance in active TB disease subjects compared to their household contacts predicted three Mtb-associated metabolites that were significantly increased in the active TB patients based on accurate mass matches: phosphatidylglycerol (PG) (16:0_18:1), lysophosphatidylinositol (Lyso-PI) (18:0) and acylphosphatidylinositol mannoside (Ac1PIM1) (56:1) (p<0.001 for all). These three metabolites provided excellent classification accuracy for active TB disease (AUC = 0.97). Ion dissociation spectra (tandem MS/MS) supported the identification of PG (16:0_18:1) and Lyso-PI (18:0) in the plasma of patients with active TB disease, though the identity of Ac1PIM1 could not be definitively confirmed. Conclusions Presence of the Mtb-associated lipid metabolites PG (16:0_18:1) and Lyso-PI (18:0) in plasma accurately identified patients with active TB disease. Consistency of in vitro and in vivo data suggests suitability for exploring these in future studies for possible development as TB disease biomarkers.
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Affiliation(s)
- Jeffrey M. Collins
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
- * E-mail:
| | - Douglas I. Walker
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Dean P. Jones
- Clinical Biomarkers Laboratory, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Ken H. Liu
- Clinical Biomarkers Laboratory, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - ViLinh T. Tran
- Clinical Biomarkers Laboratory, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Karan Uppal
- Clinical Biomarkers Laboratory, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Jennifer K. Frediani
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, United States of America
| | - Kirk A. Easley
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Neeta Shenvi
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Manoj Khadka
- Emory Integrated Lipidomics Core, Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Eric A. Ortlund
- Emory Integrated Lipidomics Core, Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Thomas R. Ziegler
- Division of Endocrinology, Metabolism and Lipids and Center for Clinical and Molecular Nutrition, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Section of Endocrinology, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, United States of America
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40
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Baliashvili D, Kempker RR, Blumberg HM, Kuchukhidze G, Merabishvili T, Aslanikashvili A, Magee MJ. A population-based tuberculosis contact investigation in the country of Georgia. Public Health Action 2018; 8:110-117. [PMID: 30271726 DOI: 10.5588/pha.18.0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/04/2018] [Indexed: 12/28/2022] Open
Abstract
Setting: Identification and screening of contacts of patients with active tuberculosis (TB) is infrequent in low- and middle-income countries. Objective: To estimate the incidence, prevalence and risk factors of latent tuberculous infection (LTBI) and active TB among contacts of newly reported smear-positive TB patients. Design: A population-based contact investigation of sputum smear-positive pulmonary TB (PTB) cases diagnosed between April and December 2012 in Georgia was conducted. LTBI was assessed using the tuberculin skin test (TST). Contacts with active TB were identified from the National TB Program surveillance database. Results: Among 896 index patients with active TB, 3133 contacts were identified and 1157 (37%) underwent a TST, 34% of whom were positive. Most contacts were household contacts (86%) and female (58%). Among contacts, the 1-year period prevalence of active TB was 3.3% (95%CI 2.70-3.98); the incidence rate was 1101 per 100 000 person-years (95%CI 822-1443). In multivariable analysis, household contacts were more likely to have LTBI (adjusted OR [aOR] 2.28, 95%CI 1.49-3.49) than close contacts. Conclusions: A high prevalence of both LTBI and active TB was identified among contacts of PTB cases. Efforts aimed at active case finding among TB contacts should improve early case detection and enhance TB control efforts.
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Affiliation(s)
- D Baliashvili
- National Center for Disease Control and Public Health, Tbilisi, Georgia.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - R R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine Atlanta, Georgia, USA
| | - H M Blumberg
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine Atlanta, Georgia, USA.,Departments of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - G Kuchukhidze
- National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - T Merabishvili
- National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - A Aslanikashvili
- National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - M J Magee
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, Georgia, USA
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41
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Comeau DL, Mishkin K, Tukvadze N, Avaliani Z, Kempker RR, Sthreshley L, Magee MJ, Eisen H, Mariam DH, Aseffa A, Blumberg HM. Mentoring in Global Health: Formative Evaluation of Tuberculosis Research Training Programs in Ethiopia and Georgia. Am J Trop Med Hyg 2018; 99:565-577. [PMID: 30014815 DOI: 10.4269/ajtmh.17-0746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Mentoring is a critical component of career development for research scientists and is related to mentee success both in terms of career selection and advancement. However, there are limited data on the role of mentoring in low- and middle-income countries (LMICs). Cross-cultural mentorship programs have the potential to foster the transfer of knowledge and the development of capacity to resource-poor settings. This formative evaluation explores the cultural context of mentoring in the countries of Georgia and Ethiopia. Results were used to build culturally relevant mentor training programs for two Global Infectious Disease Research Training Programs focused on tuberculosis funded by the Fogarty International Center at the US National Institutes of Health. Four focus group discussions were conducted with research trainees and mentors to explore the perceptions of mentorship, identify obstacles for successful mentoring, and generate recommendations to strengthen mentoring in each program situated in a LMIC. Data revealed the barriers to mentoring in Ethiopia and Georgia included gaps in knowledge about mentoring roles and responsibilities, lack of knowledge about the responsibilities of the trainee in a mentoring relationship, and the need to set clear expectations between mentors and trainees. All of the focus group participants desired formal mentor training. These data informed six key components of the development and implementation of the mentor training programs in both countries. The topics included the following: a foundation in mentoring, establishing expectations between mentees and mentors, increasing interactions between mentees and mentors, additional mentor training, a case study curriculum, and methods of evaluating mentoring relationships.
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Affiliation(s)
- Dawn L Comeau
- Rollins School of Public Health, Emory University, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | - Kathryn Mishkin
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | | | - Lisa Sthreshley
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Matthew J Magee
- School of Public Health, Georgia State University, Atlanta, Georgia
| | - Hannah Eisen
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Henry M Blumberg
- Rollins School of Public Health, Emory University, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
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42
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Whatney WE, Gandhi NR, Lindestam Arlehamn CS, Nizam A, Wu H, Quezada MJ, Campbell A, Allana S, Kabongo MM, Khayumbi J, Muchiri B, Ongalo J, Tonui J, Sasser LE, Fergus TJ, Ouma GS, Ouma SG, Beck AA, Mulligan MJ, Oladele A, Kaushal D, Cain KP, Waller L, Blumberg HM, Altman JD, Ernst JD, Rengarajan J, Day CL. A High Throughput Whole Blood Assay for Analysis of Multiple Antigen-Specific T Cell Responses in Human Mycobacterium tuberculosis Infection. J Immunol 2018. [PMID: 29540577 DOI: 10.4049/jimmunol.1701737] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antigen-specific CD4 and CD8 T cells are important components of the immune response to Mycobacterium tuberculosis, yet little information is currently known regarding how the breadth, specificity, phenotype, and function of M. tuberculosis-specific T cells correlate with M. tuberculosis infection outcome in humans. To facilitate evaluation of human M. tuberculosis-specific T cell responses targeting multiple different Ags, we sought to develop a high throughput and reproducible T cell response spectrum assay requiring low blood sample volumes. We describe here the optimization and standardization of a microtiter plate-based, diluted whole blood stimulation assay utilizing overlapping peptide pools corresponding to a functionally diverse panel of 60 M. tuberculosis Ags. Using IFN-γ production as a readout of Ag specificity, the assay can be conducted using 50 μl of blood per test condition and can be expanded to accommodate additional Ags. We evaluated the intra- and interassay variability, and implemented testing of the assay in diverse cohorts of M. tuberculosis-unexposed healthy adults, foreign-born adults with latent M. tuberculosis infection residing in the United States, and tuberculosis household contacts with latent M. tuberculosis infection in a tuberculosis-endemic setting in Kenya. The M. tuberculosis-specific T cell response spectrum assay further enhances the immunological toolkit available for evaluating M. tuberculosis-specific T cell responses across different states of M. tuberculosis infection, and can be readily implemented in resource-limited settings. Moreover, application of the assay to longitudinal cohorts will facilitate evaluation of treatment- or vaccine-induced changes in the breadth and specificity of Ag-specific T cell responses, as well as identification of M. tuberculosis-specific T cell responses associated with M. tuberculosis infection outcomes.
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Affiliation(s)
- Wendy E Whatney
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA 30329
| | - Neel R Gandhi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | | | - Azhar Nizam
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA 30322
| | - Hao Wu
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA 30322
| | - Melanie J Quezada
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA 30329
| | - Angela Campbell
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322
| | - Salim Allana
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322
| | - Mbuyi Madeleine Kabongo
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322
| | - Jeremiah Khayumbi
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu 40100, Kenya
| | - Benson Muchiri
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu 40100, Kenya
| | - Joshua Ongalo
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu 40100, Kenya
| | - Joan Tonui
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu 40100, Kenya
| | - Loren E Sasser
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA 30329
| | - Tawania J Fergus
- Department of Medicine, New York University School of Medicine, New York, NY 10016
| | - Gregory Sadat Ouma
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu 40100, Kenya
| | - Samuel Gurrion Ouma
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu 40100, Kenya
| | - Allison A Beck
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | - Mark J Mulligan
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | | | - Deepak Kaushal
- Tulane National Primate Research Center, Covington, LA 70433.,Department of Microbiology and Immunology, Tulane Health Sciences Center, New Orleans, LA 70112
| | - Kevin P Cain
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Kisumu 40100, Kenya; and
| | - Lance Waller
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA 30322
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | - John D Altman
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA 30329.,Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA 30322
| | - Joel D Ernst
- Department of Medicine, New York University School of Medicine, New York, NY 10016
| | - Jyothi Rengarajan
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA 30329; .,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322
| | - Cheryl L Day
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA 30329; .,Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA 30322
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Allana S, Shashkina E, Mathema B, Bablishvili N, Tukvadze N, Shah NS, Kempker RR, Blumberg HM, Moodley P, Mlisana K, Brust JCM, Gandhi NR. pncA Gene Mutations Associated with Pyrazinamide Resistance in Drug-Resistant Tuberculosis, South Africa and Georgia. Emerg Infect Dis 2018; 23:491-495. [PMID: 28221108 PMCID: PMC5382742 DOI: 10.3201/eid2303.161034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Although pyrazinamide is commonly used for tuberculosis treatment, drug-susceptibility testing is not routinely available. We found polymorphisms in the pncA gene for 70% of multidrug-resistant and 96% of extensively drug-resistant Mycobacterium tuberculosis isolates from South Africa and Georgia. Assessment of pyrazinamide susceptibility may be prudent before using it in regimens for drug-resistant tuberculosis.
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Kempker RR, Heinrichs MT, Nikolaishvili K, Sabulua I, Bablishvili N, Gogishvili S, Avaliani Z, Little BP, Bernheim A, Derendorf H, Blumberg HM, Vashakidze S, Peloquin CA. A comparison of linezolid lung tissue concentrations among patients with drug-resistant tuberculosis. Eur Respir J 2018; 51:51/2/1702166. [PMID: 29437945 DOI: 10.1183/13993003.02166-2017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/23/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Russell R Kempker
- Division of Infectious Diseases, Dept of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Irina Sabulua
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Nino Bablishvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Shota Gogishvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Brent P Little
- Dept of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Adam Bernheim
- Dept of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Henry M Blumberg
- Division of Infectious Diseases, Dept of Medicine, Emory University School of Medicine, Atlanta, GA, USA.,Depts of Epidemiology and Global Health, Emory Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sergo Vashakidze
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
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Kempker RR, Tukvadze N, Sthreshley L, Sharling L, Comeau DL, Magee MJ, Del Rio C, Avaliani Z, Blumberg HM. The Impact of a Fogarty International Center-Supported Tuberculosis Research Training Program in the Country of Georgia. Am J Trop Med Hyg 2018; 98:1069-1074. [PMID: 29405100 DOI: 10.4269/ajtmh.17-0667] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
In 2004, there existed limited tuberculosis (TB) research capacity in the country of Georgia. In response, a collaborative research training program (RTP) supported by a National Institutes of Health Fogarty International Center Global Infectious Diseases grant was formed between a U.S. academic institution and the National Center for Tuberculosis and Lung Disease (NCTLD) and other institutions in Georgia. We sought to assess outcomes of this RTP. The TB RTP combined didactic and mentored research training for Georgian trainees. Long-term trainees were supported for a 2-year period and with posttrainee career development mentoring. Metrics used to measure program performance included publications, grants received, and career advancement. From 2004 to 2015, 20 trainees participated in the program with 15 (75%) authoring a total of 65 publications in PubMed-listed journals. The median number of publications per trainee was six (interquartile range 2-14). A total of 16 (80%) trainees remain working in the area of TB; nine were promoted to leadership positions and three to lead research units at Georgian institutions. Ten (50%) trainees were the principal investigator (PI) of a peer-reviewed external grant after Fogarty-supported training, and 40% served as research mentors. Annual TB-related research funding at the NCTLD increased from $5,000 in 2005 to ∼$1.5 million in 2017. A Georgian Fogarty trainee was either PI, site PI, or coinvestigator on > 90% of all research funding. We believe that the NIH Fogarty-funded TB research training grant has made critical contributions to increasing the TB-related research infrastructure and capacity in Georgia, particularly at the NCTLD.
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Affiliation(s)
- Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Lisa Sthreshley
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Lisa Sharling
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Dawn L Comeau
- Behavioral Sciences and Health Education, Rollins School of Public Health of Emory University, Atlanta, Georgia
| | - Matthew J Magee
- Georgia State University, School of Public Health, Atlanta, Georgia
| | - Carlos Del Rio
- Hubert Department of Global Health and Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Henry M Blumberg
- Hubert Department of Global Health and Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Adelman MW, McFarland DA, Tsegaye M, Aseffa A, Kempker RR, Blumberg HM. Cost-effectiveness of WHO-Recommended Algorithms for TB Case Finding at Ethiopian HIV Clinics. Open Forum Infect Dis 2017; 5:ofx269. [PMID: 29399596 PMCID: PMC5788063 DOI: 10.1093/ofid/ofx269] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background The World Health Organization (WHO) recommends active tuberculosis (TB) case finding and a rapid molecular diagnostic test (Xpert MTB/RIF) to detect TB among people living with HIV (PLHIV) in high-burden settings. Information on the cost-effectiveness of these recommended strategies is crucial for their implementation. Methods We conducted a model-based cost-effectiveness analysis comparing 2 algorithms for TB screening and diagnosis at Ethiopian HIV clinics: (1) WHO-recommended symptom screen combined with Xpert for PLHIV with a positive symptom screen and (2) current recommended practice algorithm (CRPA; based on symptom screening, smear microscopy, and clinical TB diagnosis). Our primary outcome was US$ per disability-adjusted life-year (DALY) averted. Secondary outcomes were additional true-positive diagnoses, and false-negative and false-positive diagnoses averted. Results Compared with CRPA, combining a WHO-recommended symptom screen with Xpert was highly cost-effective (incremental cost of $5 per DALY averted). Among a cohort of 15 000 PLHIV with a TB prevalence of 6% (900 TB cases), this algorithm detected 8 more true-positive cases than CRPA, and averted 2045 false-positive and 8 false-negative diagnoses compared with CRPA. The WHO-recommended algorithm was marginally costlier ($240 000) than CRPA ($239 000). In sensitivity analysis, the symptom screen/Xpert algorithm was dominated at low Xpert sensitivity (66%). Conclusions In this model-based analysis, combining a WHO-recommended symptom screen with Xpert for TB diagnosis among PLHIV was highly cost-effective ($5 per DALY averted) and more sensitive than CRPA in a high-burden, resource-limited setting.
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Affiliation(s)
- Max W Adelman
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Deborah A McFarland
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Henry M Blumberg
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Magee MJ, Darchia L, Kipiani M, Chakhaia T, Kempker RR, Tukvadze N, Berg CJ, Blumberg HM. Smoking behavior and beliefs about the impact of smoking on anti-tuberculosis treatment among health care workers. Int J Tuberc Lung Dis 2017; 21:1049-1055. [PMID: 28664827 DOI: 10.5588/ijtld.17.0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Tuberculosis (TB) health care facilities throughout Georgia. OBJECTIVE To describe smoking behaviors among health care workers (HCWs) at TB facilities and determine HCWs' knowledge and beliefs regarding the impact of tobacco use on anti-tuberculosis treatment. DESIGN Cross-sectional survey from May to December 2014 in Georgia. Adult HCWs (age 18 years) at TB facilities were eligible. We administered a 60-question anonymous survey about tobacco use and knowledge of the effect of smoking on anti-tuberculosis treatment. RESULTS Of the 431 HCWs at TB facilities who participated, 377 (87.5%) were female; the median age was 50 years (range 20-77). Overall, 59 (13.7%) HCWs were current smokers and 35 (8.1%) were past smokers. Prevalence of current smoking was more common among physicians than among nurses (18.6% vs. 7.9%, P < 0.0001). Among HCWs, 115 (26.7%) believed smoking does not impact anti-tuberculosis treatment, and only 25.3% of physicians/nurses received formal training in smoking cessation approaches. Physicians who smoked were significantly more likely to believe that smoking does not impact anti-tuberculosis treatment than non-smoking physicians (aOR 5.11, 95%CI 1.46-17.90). CONCLUSION Additional education about the effect of smoking on TB treatment outcomes is needed for staff of TB health care facilities in Georgia. Nurses and physicians need more training about smoking cessation approaches for patients with TB.
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Affiliation(s)
- M J Magee
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - L Darchia
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - M Kipiani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - T Chakhaia
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - R R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta
| | - N Tukvadze
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - C J Berg
- Department of Behavioral Sciences and Health Education
| | - H M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Department of Epidemiology and Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Mengistu BS, Vins H, Kelly CM, McGee DR, Spicer JO, Derbew M, Bekele A, Mariam DH, del Rio C, Blumberg HM, Comeau DL. Student and faculty perceptions on the rapid scale-up of medical students in Ethiopia. BMC Med Educ 2017; 17:11. [PMID: 28086953 PMCID: PMC5237354 DOI: 10.1186/s12909-016-0849-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 12/15/2016] [Indexed: 05/31/2023]
Abstract
BACKGROUND Ethiopia is a country of over 94 million people that has a severe physician shortage with approximately only 2.5 physicians per 100,000 persons. Recently, the Ethiopian government implemented a "flood and retain" initiative to rapidly increase the quantity of physicians in Ethiopia. Consequently, medical student enrollment at Addis Ababa University (AAU) School of Medicine increased from 100 to approximately 300-400 students per class. This study evaluated the impact of the rapid scale-up in the number of medical students on the quality of medical education at AAU and the impact of the U.S. government-funded Medical Education Partnership Initiative (MEPI) grant awarded to AAU to provide resources to strengthen the quality of medical education at AAU. METHODS Qualitative, semi-structured, in-depth interviews were conducted with 22 key informants including faculty members, administrators and medical students at AAU. The audio recordings were transcribed verbatim and interview data were analyzed with thematic analysis. RESULTS Four key themes emerged from the data. Overall, participants perceived a decrease in the quality of medical education at AAU due to challenges created by the rapid scale-up in the number of medical students. Positive learning environments were described as difficult to achieve due to overcrowding in classrooms and the limited numbers of textbooks. Overall, participants stated that infrastructure improvement is needed to provide adequate medical student training. The medical education initiatives implemented and funded by MEPI have provided significant resources to support the medical student curriculum but additional resources are required to accommodate a large student body. CONCLUSIONS The unprecedented rapid scale-up of medical students has impacted multiple facets of medical education at AAU. It is important to consider the perspectives of students and faculty in order to focus future medical education policies, MEPI programming and the allocation of resources.
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Affiliation(s)
- Brittney S. Mengistu
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Rm 510, Atlanta, GA 30322 USA
| | - Holly Vins
- Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322 USA
| | - Caitrin M Kelly
- Emory University School of Medicine, 1599 Clifton Rd, 6th fl, Atlanta, GA 30322 USA
| | - Daphne R. McGee
- Emory University School of Law and Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322 USA
| | - Jennifer O. Spicer
- Department of Medicine, Emory University School of Medicine, 1599 Clifton Rd, 6th fl, Atlanta, GA 30322 USA
| | - Miliard Derbew
- College of Health Sciences, Addis Ababa University, Black Lion Hospital Campus, Second Floor, Office No 35, PO Box 5729, Addis Ababa, Ethiopia
| | - Abebe Bekele
- School of Medicine, Addis Ababa University, PO Box 9086, Addis Ababa, Ethiopia
| | - Damen Haile Mariam
- School of Public Health, Addis Ababa University, PO Box 9086, Addis Ababa, Ethiopia
| | - Carlos del Rio
- Hubert Department of Global Health, Rollins School of Public Health and, Department of Medicine, Emory University School of Medicine, 1518 Clifton Rd #7011, Claudia Nance Rollins Bldg, Atlanta, GA 30322 USA
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine and Departments of Epidemiology and Global Health Rollins School of Public Health, Emory University, 1599 Clifton Rd, 6th fl, Atlanta, GA 30322 USA
| | - Dawn L. Comeau
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Rm 510, Atlanta, GA 30322 USA
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Holloway KP, Rouphael NG, Wells JB, King MD, Blumberg HM. Polymyxin B and Doxycycline Use in Patients with Multidrug-Resistant Acinetobacter baumannii Infections in the Intensive Care Unit. Ann Pharmacother 2016; 40:1939-45. [PMID: 17018688 DOI: 10.1345/aph.1h353] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Multidrug-resistant Acinetobacter baumannii (MDR-Ab) has emerged as an increasingly problematic cause of hospital-acquired infections in the intensive care unit (ICU). MDR-Ab is resistant to most standard antimicrobials but often retains susceptibility to polymyxin B and doxycycline. Objective: To evaluate the efficacy and toxicity of polymyxin B and doxycycline in the treatment of MDR-Ab infections. Methods: A retrospective chart review was conducted between March 2002 and May 2005 in patients who received doxycycline or polymyxin B for treatment of MDR-Ab infections in ICUs within Grady Memorial Hospital, Atlanta, GA. Results: Thirty-seven patients with MDR-Ab infections were treated with polymyxin B or doxycycline. Median age was 41 years and median ICU length of stay was 18 days prior to acquisition of MDR-Ab. Clinical cure was observed in 22 of 29 (76%) evaluable patients treated with polymyxin B and 2 of 4 (50%) patients treated with doxycycline. In patients with follow-up cultures, microbiological cure was observed in 17 of 21 (81%) patients treated with polymyxin B and 2 of 3 (67%) patients treated with doxycycline. Nephrotoxicity developed in 21% (7 of 33) of patients who received polymyxin B. Neurotoxicity was observed in 2 (6%) patients who received polymyxin B. No adverse reactions were observed with doxycycline. Overall, crude mortality was 27% (9 of 33) and 75% (3 of 4) among those who received polymyxin B and doxycycline, respectively. Three (9%) deaths were attributed to polymyxin B treatment failure, and no deaths were attributed to doxycycline treatment failure. Conclusions: Polymyxin B was effectively used to treat a substantial proportion of critically ill patients with MDR-Ab infection and was associated with a similar rate of nephrotoxicity as previously reported. Doxycycline monotherapy was used in a limited number of patients for the treatment of MDR-Ab; further evaluation of its efficacy in larger numbers of patients is warranted.
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Affiliation(s)
- Katherine P Holloway
- Internal Medicine, Department of Clinical and Administrative Sciences, Mercer University College of Pharmacy and Health Sciences, Atlanta, GA 30341-4155, USA.
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50
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Hensel RL, Kempker RR, Tapia J, Oladele A, Blumberg HM, Magee MJ. Increased risk of latent tuberculous infection among persons with pre-diabetes and diabetes mellitus. Int J Tuberc Lung Dis 2016; 20:71-8. [PMID: 26688531 DOI: 10.5588/ijtld.15.0457] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
SETTING Although diabetes mellitus (DM) is an established risk factor for active tuberculosis (TB) disease, little is known about the association between pre-DM, DM, and latent tuberculous infection (LTBI). OBJECTIVE To estimate the association between DM and LTBI. DESIGN We conducted a cross-sectional study among recently arrived refugees seen at a health clinic in Atlanta, GA, USA, between 2013 and 2014. Patients were screened for DM using glycosylated-hemoglobin (HbA1c), and for LTBI using the QuantiFERON(®)-TB (QFT) test. HbA1c and QFT results, demographic information, and medical history were abstracted from patient charts. RESULTS Among 702 included patients, 681 (97.0%) had HbA1c and QFT results. Overall, 54 (7.8%) patients had DM and 235 (33.8%) had pre-DM. LTBI was prevalent in 31.3% of the refugees. LTBI prevalence was significantly higher (P < 0.01) among patients with DM (43.4%) and pre-DM (39.1%) than in those without DM (25.9%). Refugees with DM (adjusted OR [aOR] 2.3, 95%CI 1.2-4.5) and pre-DM (aOR 1.7, 95%CI 1.1-2.4) were more likely to have LTBI than those without DM. CONCLUSION Refugees with DM or pre-DM from high TB burden countries were more likely to have LTBI than those without DM. Dysglycemia may impair the immune defenses involved in preventing Mycobacterium tuberculosis infection.
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Affiliation(s)
- R L Hensel
- School of Medicine, Emory University, Atlanta, Georgia, USA
| | - R R Kempker
- School of Medicine, Emory University, Atlanta, Georgia, USA; Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - J Tapia
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - A Oladele
- DeKalb County Board of Health, Decatur, Georgia, USA
| | - H M Blumberg
- School of Medicine, Emory University, Atlanta, Georgia, USA; Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA; Departments of Epidemiology and Global Health, Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - M J Magee
- Departments of Epidemiology and Global Health, Emory Rollins School of Public Health, Atlanta, Georgia, USA; Division of Epidemiology and Biostatistics, Georgia State University, School of Public Health, Atlanta, Georgia, USA
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