scholarly journals Multidisciplinary management of difficult-to-treat drug resistant tuberculosis: a review of cases presented to the national consilium in Uganda

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Joseph Baruch Baluku ◽  
Richard Katuramu ◽  
Joshua Naloka ◽  
Enock Kizito ◽  
Martin Nabwana ◽  
...  
Keyword(s):  
Treatment Outcomes ◽  
Psychiatric Symptoms ◽  
Treatment Success ◽  
Secondary Analysis ◽  
Prognostic Indicators ◽  
High Dose ◽  
Drug Resistant ◽  
Drug Resistant Tuberculosis ◽  
Treatment Regimens ◽  
Resistant Tuberculosis

Abstract Background Patients with drug resistant tuberculosis (DR-TB) with comorbidities and drug toxicities are difficult to treat. Guidelines recommend such patients to be managed in consultation with a multidisciplinary team of experts (the “TB consilium”) to optimise treatment regimens. We describe characteristics and treatment outcomes of DR-TB cases presented to the national DR-TB consilium in Uganda between 2013 and 2019. Methods We performed a secondary analysis of data from a nation-wide retrospective cohort of DR-TB patients with poor prognostic indicators in Uganda. Patients had a treatment outcome documented between 2013 and 2019. Characteristics and treatment outcomes were compared between cases reviewed by the consilium with those that were not reviewed. Results Of 1,122 DR-TB cases, 189 (16.8%) cases from 16 treatment sites were reviewed by the consilium, of whom 86 (45.5%) were reviewed more than once. The most frequent inquiries (N = 308) from DR-TB treatment sites were construction of a treatment regimen (38.6%) and management of side effects (24.0%) while the most frequent consilium recommendations (N = 408) were a DR-TB regimen (21.7%) and “observation while on current regimen” (16.6%). Among the cases reviewed, 152 (80.4%) were from facilities other than the national referral hospital, 113 (61.1%) were aged ≥ 35 years, 72 (40.9%) were unemployed, and 26 (31.0%) had defaulted antiretroviral therapy. Additionally, 141 (90.4%) had hepatic injury, 55 (91.7%) had bilateral hearing loss, 20 (4.8%) had psychiatric symptoms and 14 (17.7%) had abnormal baseline systolic blood pressure. Resistance to second-line drugs (SLDs) was observed among 9 (4.8%) cases while 13 (6.9%) cases had previous exposure to SLDs. Bedaquiline (13.2%, n = 25), clofazimine (28.6%, n = 54), high-dose isoniazid (22.8%, n = 43) and linezolid (6.7%, n = 13) were more frequently prescribed among cases reviewed by the consilium than those not reviewed. Treatment success was observed among 126 (66.7%) cases reviewed. Conclusion Cases reviewed by the consilium had several comorbidities, drug toxicities and a low treatment success rate. Consilia are important “gatekeepers” for new and repurposed drugs. There is need to build capacity of lower health facilities to construct DR-TB regimens and manage adverse effects.

scholarly journals Gender differences among patients with drug resistant tuberculosis and HIV co-infection in Uganda: a countrywide retrospective cohort study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Joseph Baruch Baluku ◽  
David Mukasa ◽  
Felix Bongomin ◽  
Anna Stadelmann ◽  
Edwin Nuwagira ◽  
...  
Keyword(s):  
Gender Differences ◽  
Treatment Outcomes ◽  
Treatment Success ◽  
High Dose ◽  
Drug Resistant ◽  
Drug Resistant Tuberculosis ◽  
Men And Women ◽  
Predictors Of Mortality ◽  
Resistant Tuberculosis ◽  
History Of

Abstract Background Gender differences among patients with drug resistant tuberculosis (DRTB) and HIV co-infection could affect treatment outcomes. We compared characteristics and treatment outcomes of DRTB/HIV co-infected men and women in Uganda. Methods We conducted a retrospective chart review of patients with DRTB from 16 treatment sites in Uganda. Eligible patients were aged ≥ 18 years, had confirmed DRTB, HIV co-infection and a treatment outcome registered between 2013 and 2019. We compared socio-demographic and clinical characteristics and tuberculosis treatment outcomes between men and women. Potential predictors of mortality were determined by cox proportional hazard regression analysis that controlled for gender. Statistical significance was set at p < 0.05. Results Of 666 DRTB/HIV co-infected patients, 401 (60.2%) were men. The median (IQR) age of men and women was 37.0 (13.0) and 34.0 (13.0) years respectively (p < 0.001). Men were significantly more likely to be on tenofovir-based antiretroviral therapy (ART), high-dose isoniazid-containing DRTB regimen and to have history of cigarette or alcohol use. They were also more likely to have multi-drug resistant TB, isoniazid and streptomycin resistance and had higher creatinine, aspartate and gamma-glutamyl aminotransferase and total bilirubin levels. Conversely, women were more likely to be unemployed, unmarried, receive treatment from the national referral hospital and to have anemia, a capreomycin-containing DRTB regimen and zidovudine-based ART. Treatment success was observed among 437 (65.6%) and did not differ between the genders. However, mortality was higher among men than women (25.7% vs. 18.5%, p = 0.030) and men had a shorter mean (standard error) survival time (16.8 (0.42) vs. 19.0 (0.46) months), Log Rank test (p = 0.046). Predictors of mortality, after adjusting for gender, were cigarette smoking (aHR = 4.87, 95% CI 1.28–18.58, p = 0.020), an increase in alanine aminotransferase levels (aHR = 1.05, 95% CI 1.02–1.07, p < 0.001), and history of ART default (aHR = 3.86, 95% CI 1.31–11.37, p = 0.014) while a higher baseline CD4 count was associated with lower mortality (aHR = 0.94, 95% CI 0.89–0.99, p = 0.013 for every 10 cells/mm3 increment). Conclusion Mortality was higher among men than women with DRTB/HIV co-infection which could be explained by several sociodemographic and clinical differences.

scholarly journals Trends, Characteristics and Treatment Outcomes of Patients with Drug-Resistant Tuberculosis in Uzbekistan: 2013–2018

2021 ◽  
Vol 18 (9) ◽  
pp. 4663
Author(s):  
Khasan Safaev ◽  
Nargiza Parpieva ◽  
Irina Liverko ◽  
Sharofiddin Yuldashev ◽  
Kostyantyn Dumchev ◽  
...  
Keyword(s):  
Risk Factors ◽  
Treatment Outcomes ◽  
Treatment Success ◽  
National Level ◽  
Drug Resistant ◽  
Drug Resistant Tuberculosis ◽  
Loss To Follow Up ◽  
Resistant Tuberculosis ◽  
Mdr Tb

Uzbekistan has a high burden of drug-resistant tuberculosis (TB). Although conventional treatment for multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) has been available since 2013, there has been no systematic documentation about its use and effectiveness. We therefore documented at national level the trends, characteristics, and outcomes of patients with drug-resistant TB enrolled for treatment from 2013–2018 and assessed risk factors for unfavorable treatment outcomes (death, failure, loss to follow-up, treatment continuation, change to XDR-TB regimen) in patients treated in Tashkent city from 2016–2017. This was a cohort study using secondary aggregate and individual patient data. Between 2013 and 2018, MDR-TB numbers were stable between 2347 and 2653 per annum, while XDR-TB numbers increased from 33 to 433 per annum. At national level, treatment success (cured and treatment completed) for MDR-TB decreased annually from 63% to 57%, while treatment success for XDR-TB increased annually from 24% to 57%. On multivariable analysis, risk factors for unfavorable outcomes, death, and loss to follow-up in drug-resistant TB patients treated in Tashkent city included XDR-TB, male sex, increasing age, previous TB treatment, alcohol abuse, and associated comorbidities (cardiovascular and liver disease, diabetes, and HIV/AIDS). Reasons for these findings and programmatic implications are discussed.

scholarly journals Cost comparison of nine-month treatment regimens with 20-month standardized care for the treatment of rifampicin-resistant/multi-drug resistant tuberculosis in Nigeria

PLoS ONE ◽  
2020 ◽  
Vol 15 (12) ◽  
pp. e0241065
Author(s):  
Florence O. Bada ◽  
Nick Blok ◽  
Evaezi Okpokoro ◽  
Saswata Dutt ◽  
Christopher Akolo ◽  
...  
Keyword(s):  
Treatment Regimen ◽  
Treatment Success ◽  
Cost Savings ◽  
Drug Resistant ◽  
Second Line ◽  
Success Rates ◽  
Drug Resistant Tuberculosis ◽  
Treatment Regimens ◽  
Resistant Tuberculosis ◽  
Mdr Tb

Background Globally, drug resistant tuberculosis (DR-TB) continues to be a public health threat. Nigeria, which accounts for a significant proportion of the global burden of rifampicin/multi-drug resistant-TB (RR/MDR-TB) had a funding gap of $168 million dollars for TB treatment in 2018. Since 2010, Nigeria has utilized five different models of care for RR/MDR-TB (Models A-E); Models A, B and C based on a standardized WHO-approved treatment regimen of 20–24 months, were phased out between 2015 and 2019 and replaced by Models D and E. Model D is a fully ambulatory model of 9–12 months during which a shorter treatment regimen including a second-line injectable agent is utilized. Model E is identical to Model D but has patients hospitalized for the first four months of care while Model F which is to be introduced in 2020, is a fully ambulatory, oral bedaquiline-containing shorter treatment regimen of 9–12 months. Treatment models for RR/MDR-TB of 20–24 months duration have had treatment success rates of 52–66% while shorter treatment regimens have reported success rates of 85% and above. In addition, replacing the second-line injectable agent in a shorter treatment regimen with bedaquiline has been found to further improve treatment success in patients with fluoroquinolone-susceptible RR/MDR-TB. Reliable cost data for RR/MDR-TB care are limited, specifically costs of models that utilize shorter treatment regimens and which are vital to guide Nigeria through the provision of RR/MDR-TB care at scale. We therefore conducted a cost analysis of shorter treatment regimens in use and to be used in Nigeria (Models D, E and F) and compared them to three models of longer duration utilized previously in Nigeria (Models A, B and C) to identify any changes in cost from transitioning from Models A-C to Models D-F and opportunities for cost savings. Methods We obtained costs for TB diagnostic and monitoring tests, in-patient and out-patient care from a previous study, inflated these costs to 2019 NGN and then converted to 2020 USD. We obtained other costs from the average of six health facilities and drug costs from the global drug facility. We modeled treatment on strict adherence to two Nigerian National guidelines for programmatic and clinical management of drug-resistant tuberculosis. Results We estimated that the total costs of care from the health sector perspective for Models D, E and F were $4,334, $7,705 and $3,420 respectively. This is significantly lower than the costs of Models A, B and C which were $14,781, $12, 113, $7,572 respectively. Conclusion Replacing Models A–C with Models D and E reduced the costs of RR/MDR-TB care in Nigeria by approximately $5,470 (48%) per patient treated and transitioning from Models D and E to Model F would result in further cost savings of $914 to $4,285 (21 to 56%) for every patient placed on Model F. If the improved outcomes of patients managed using bedaquiline-containing shorter treatment regimens in other countries can be attained in Nigeria, Model F would be the recommended model for the scale up of RR/MDR-TB care in Nigeria.

scholarly journals Treatment outcomes of patients with multidrug and extensively drug-resistant tuberculosis in Zhejiang, China

2021 ◽  
Vol 26 (1) ◽  
Author(s):  
Ming-Wu Zhang ◽  
Lin Zhou ◽  
Yu Zhang ◽  
Bin Chen ◽  
Ying Peng ◽  
...  
Keyword(s):  
Treatment Outcomes ◽  
Treatment Success ◽  
Drug Resistant ◽  
Drug Resistant Tuberculosis ◽  
Resistant Tuberculosis ◽  
Extensively Drug Resistant ◽  
Cavitary Disease ◽  
Referral Hospitals ◽  
Baseline Weight ◽  
Poor Outcomes

Abstract Background The aim of this study was to assess the treatment outcomes of multidrug and extensively drug-resistant tuberculosis (M/XDR-TB) in Zhejiang, China and to evaluate possible risk factors associated with poor outcomes of M/XDR-TB. Methods Two-hundred-and-sixty-two patients having M/XDR-TB who received the diagnosis and treatment at nine referral hospitals from 1 January 2016 to 31 December 2016 in Zhejiang, China were included. All patients received second-line regimens recommended by WHO under the DOTS-Plus strategy. Results Among the 262 patients, the treatment success rate was 55.34% (n = 145) with 53.44% (n = 140) cured and 1.91% (n = 5) who completed treatment, 62 (23.66%) failed, 27 (10.31%) died, 16 (6.11%) defaulted and 12 (4.58%) transferred out. Forty (64.52%) of the 62 M/XDR-TB patients who failed treatment were due to adverse effects in the first 10 months of treatment. Eighteen patients (6.37%) had XDR-TB. Treatment failure was significantly higher among patients with XDR-TB at 50% than that among patients with non-XDR-TB at 21.72% (P = 0.006). Failure outcomes were associated with a baseline weight less than 50 kg (OR, 8.668; 95% CI 1.679–44.756; P = 0.010), age older than 60 years (OR, 9.053; 95% CI 1.606–51.027; P = 0.013), hemoptysis (OR, 8.928; 95% CI 1.048–76.923; P = 0.045), presence of cavitary diseases (OR, 10.204; 95% CI 2.032–52.631; P = 0.005), or treatment irregularity (OR, 47.619; 95% CI 5.025–500; P = 0.001). Conclusion Treatment outcomes for M/XDR-TB under the DOTS-Plus strategy in Zhejiang, China were favorable but still not ideal. Low body weight (< 50 kg), old age (> 60 years), severe symptoms of TB including cavitary disease, hemoptysis and irregular treatment were independent prognostic factors for failure outcomes in patients with M/XDR-TB.

scholarly journals Impacts of social support on the treatment outcomes of drug-resistant tuberculosis: a systematic review and meta-analysis

BMJ Open ◽  
2020 ◽  
Vol 10 (10) ◽  
pp. e036985
Author(s):  
Shuqin Wen ◽  
Jia Yin ◽  
Qiang Sun
Keyword(s):  
Social Support ◽  
Treatment Outcomes ◽  
Low Income ◽  
Meta Analysis ◽  
Treatment Success ◽  
Drug Resistant ◽  
Drug Resistant Tuberculosis ◽  
Middle Income ◽  
Material Support ◽  
Resistant Tuberculosis

ObjectiveTo assess the effectiveness of social support on treatment success promotion or lost to follow-up (LTFU) reduction for patients with drug-resistant tuberculosis (DR-TB).DesignWe searched Pubmed, Web of Science, Embase, Scopus and Medline databases until 18 June 2020 for interventional or mixed-method studies which reported social support and treatment outcomes of DR-TB patients. Two independent reviewers extracted data and disagreements were resolved by consensus with a third reviewer. Random-effects meta-analysis was performed to calculate the OR and 95% CI for the effects of social support on the improvement of treatment outcomes and the heterogeneity and risk of bias were assessed.SettingLow-income and middle-income countries.ParticipantsDR-TB patients.OutcomesTreatment success is defined as the combination of the cured and treatment completion, and LTFU is measured as treatment being interrupted for two consecutive months or more.ResultsAmong 173 articles selected for full-text review, 162 were excluded through independent review (kappa=0.87) and 10 studies enrolling 1621 DR-TB patients in eight countries were included for qualitative analysis. In these studies, the most frequently introduced social support was material support (10 studies), followed by informational (eight studies), emotional (seven studies) and companionship support (four studies). Seven studies that reported treatment outcomes in both intervention arm and control arm are qualified for meta-analysis. An encouraging improvement on treatment success rate (OR: 2.58; 95% CI: 1.80 to 3.69) was found when material support was integrated into social support packages and no heterogeneity was observed (I1 of 0%, Q test p=0.72). Reduction on LTFU rate (OR: 0.17; 95% CI: 0.05 to 0.55) was also noted when material support was available but substantial heterogeneity was found (I2 of 80%, Q test p=0.002).ConclusionMaterial support appeared feasible and effective to improve treatment success for DR-TB patients combined with other social support interventions.PROSPERO registration numberCRD42019140824.

scholarly journals Evaluation of drug-resistant tuberculosis treatment outcome in Portugal, 2000–2016

PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0250028
Author(s):  
Olena Oliveira ◽  
Rita Gaio ◽  
Margarida Correia-Neves ◽  
Teresa Rito ◽  
Raquel Duarte
Keyword(s):  
Treatment Outcome ◽  
Hiv Infection ◽  
Treatment Outcomes ◽  
Treatment Success ◽  
Case Fatality ◽  
Drug Resistant ◽  
Drug Resistant Tuberculosis ◽  
Factors Associated ◽  
Resistant Tuberculosis ◽  
Mdr Tb

Treatment of drug-resistant tuberculosis (TB), which is usually less successful than that of drug-susceptible TB, represents a challenge for TB control and elimination. We aimed to evaluate treatment outcomes and to identify the factors associated with death among patients with MDR and XDR-TB in Portugal. We assessed MDR-TB cases reported for the period 2000–2016, using the national TB Surveillance System. Treatment outcomes were defined according to WHO recommendations. We identified the factors associated with death using logistic regression. We evaluated treatment outcomes of 294 MDR- and 142 XDR-TB patients. The treatment success rate was 73.8% among MDR- and 62.7% among XDR-TB patients (p = 0.023). The case-fatality rate was 18.4% among MDR- and 23.9% among XDR-TB patients. HIV infection (OR 4.55; 95% CI 2.31–8.99; p < 0.001) and resistance to one or more second-line injectable drugs (OR 2.73; 95% CI 1.26–5.92; p = 0.011) were independently associated with death among MDR-TB patients. HIV infection, injectable drug use, past imprisonment, comorbidities, and alcohol abuse are conditions that were associated with death early on and during treatment. Early diagnosis of MDR-TB and further monitoring of these patients are necessary to improve treatment outcome.

Exploring patient-provider factors for risk of developing Multi-drug Resistance Tuberculosis in Southern Ethiopia: Qualitative Operation Research (Preprint)

2019 ◽  
Author(s):  
Yitagesu Habtu ◽  
Tesema Bereku ◽  
Girma Alemu ◽  
Ermias Abera
Keyword(s):  
Phenomenological Study ◽  
Treatment Success ◽  
World Health ◽  
Multi Drug Resistance ◽  
Southern Ethiopia ◽  
Drug Resistant ◽  
Related Factors ◽  
Drug Resistant Tuberculosis ◽  
Resistant Tuberculosis ◽  
Multi Drug Resistant Tuberculosis

BACKGROUND Ethiopia is one of among thirty high burden countries of multi-drug resistant tuberculosis (MDR-TB) in the regions of world health organization. Contextual evidence on the emergence of the disease is limited at a program level. OBJECTIVE The aim of the study is to explore patient-provider factors that may facilitate the emergence of multi-drug resistant tuberculosis. METHODS We used a phenomenological study design of qualitative approach from June to July, 2015. We conducted ten in-depth interviews and 4 focus group discussions with purposely selected patients and providers. We designed and used an interview guide to collect data. Verbatim transcribes were exported to open code 3.4 for emerging thematic analysis. Domain summaries were used to support core interpretation. RESULTS The study explored patient-provider factors facilitating the emergence of multi-drug resistant tuberculosis. These factors as underlying, health system and patient-related factors. Especially, the a shows conflicting finding between having a history of discontinuing drug-susceptible tuberculosis and emergence of multi-drug resistant tuberculosis. CONCLUSIONS The patient-provider factors may result in poor early case identification, adherence to and treatment success in drug sensitive or multi-drug resistant tuberculosis. Our study implies the need for awareness creation about multi-drug resistant tuberculosis for patients and further familiarization for providers. This study also shows that patients developed multi-drug resistant tuberculosis though they had never discontinued their drug-susceptible tuberculosis treatment. Therefore, further studies may require for this discording finding.

scholarly journals Spatial clustering of drug-resistant tuberculosis in Hunan province, China: an ecological study

BMJ Open ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. e043685
Author(s):  
Kefyalew Addis Alene ◽  
Zuhui Xu ◽  
Liqiong Bai ◽  
Hengzhong Yi ◽  
Yunhong Tan ◽  
...  
Keyword(s):  
Treatment Outcomes ◽  
Cumulative Incidence ◽  
Ecological Study ◽  
Spatial Clustering ◽  
Hunan Province ◽  
Drug Resistant ◽  
Drug Resistant Tuberculosis ◽  
The North ◽  
Resistant Tuberculosis ◽  
Over Time

ObjectiveThis study aimed to investigate the spatial distribution of drug-resistant tuberculosis (DR-TB) in Hunan province, China.MethodsAn ecological study was conducted using DR-TB data collected from the Tuberculosis Control Institute of Hunan Province between 2012 and 2018. Spatial clustering of DR-TB was explored using the Getis-Ord statistic. A Poisson regression model was fitted with a conditional autoregressive prior structure, and with posterior parameters estimated using a Bayesian Markov chain Monte Carlo simulation, to quantify associations with possible risk factors and identify clusters of high DR-TB risk.ResultsA total of 2649 DR-TB patients were reported to Hunan TB Control Institute between 2012 and 2018. The majority of the patients were male (74.8%, n=1983) and had a history of TB treatment (88.53%, n=2345). The proportion of extensively DR-TB among all DR-TB was 3.3% (95% CI 2.7% to 4.1%), which increased from 2.8% in 2012 to 4.4% in 2018. Of 1287 DR-TB patients with registered treatment outcomes, 434 (33.8%) were cured, 198 (15.3%) completed treatment, 92 (7.1%) died, 108 (8.3%) had treatment failure and 455 (35.3%) were lost to follow-up. Half (50.9%, n=655) had poor treatment outcomes. The annual cumulative incidence rate of notified DR-TB increased over time from 0.25 per 100 000 people in 2012 to 0.83 per 100 000 people in 2018. Substantial spatial heterogeneity was observed, and hotspots were detected in counties located in the North and East parts of Hunan province. The cumulative incidence of notified DR-TB was significantly associated with urban communities.ConclusionThe annual incidence of notified DR-TB increased over time in Hunan province. Spatial clustering of DR-TB was detected and significantly associated with urbanisation. This finding suggests that targeting interventions to the highest risk areas and population groups would be effective in reducing the burden and ongoing transmission of DR-TB.

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