Diagnosis and management of multidrug resistant tuberculosis

BackgroundEngagement of healthcare providers is one of the World Health Organization strategies devised for prevention and provision of patient centered care for multidrug resistant tuberculosis. The need for current research question rose because of the gaps in evidence on health professional’s engagement and its factors in multidrug resistant tuberculosis service delivery as per the protocol in the prevention and management of multidrug resistant tuberculosis.PurposeThe purpose of this study was to explore the level of health care providers’ engagement in multidrug resistant tuberculosis prevention and management and influencing factors in Hadiya Zone health facilities, Southern Ethiopia.MethodsDescriptive phenomenological qualitative study design was employed between 02 May and 09 May, 2019. We conducted a key informant interview and focus group discussions using purposely selected healthcare experts working as directly observed treatment short course providers in multidrug resistant tuberculosis treatment initiation centers, program managers, and focal persons. Verbatim transcripts were translated to English and exported to open code 4.02 for line-by-line coding and categorization of meanings into same emergent themes. Thematic analysis was conducted based on predefined themes for multidrug resistant tuberculosis prevention and management and core findings under each theme were supported by domain summaries in our final interpretation of the results. To maintain the rigors, Lincoln and Guba’s parallel quality criteria of trustworthiness was used particularly, credibility, dependability, transferability, confirmability and reflexivity.ResultsTotal of 26 service providers, program managers, and focal persons were participated through four focus group discussion and five key informant interviews. The study explored factors for engagement of health care providers in the prevention and management of multidrug resistant tuberculosis in five emergent themes such as patients’ causes, perceived susceptibility, seeking support, professional incompetence and poor linkage of the health care facilities. Our findings also suggest that service providers require additional training, particularly in programmatic management of drug-resistant tuberculosis.ConclusionThe study explored five emergent themes: patient’s underlying causes, seeking support, perceived susceptibility, professionals’ incompetence and health facilities poor linkage. Community awareness creation to avoid fear of discrimination through provision of support for those with multidrug resistant tuberculosis is expected from health care providers using social behavioral change communication strategies. Furthermore, program managers need to follow the recommendations of World Health Organization for engaging healthcare professionals in the prevention and management of multidrug resistant tuberculosis and cascade trainings in clinical programmatic management of the disease for healthcare professionals.

To improve the effectiveness of case detection and treatment of multi-drug resistant tuberculosis (MDR-TB) by implementing a mechanism of cooperation between hospitals and centers for disease control (CDC). Since 1 March 2010, a new mechanism of cooperation between hospitals and CDCs had been established in 5 cities including Daqing, Quzhou, Puyang, Tianjin and Wanzhou in China. Data of MDR-TB case-detection, treatment and economic burdens before the intervention (January 1, 2006-June 30, 2009) and after the intervention (March 1, 2010-February 29, 2012) were collected. Then all data were analyzed by statistical method. After the intervention, samples from 68.4% (5 287/7 733) of smear-positive TB patients in the study regions underwent TB drug-resistant testing, and the number of the detected MDR-TB cases were 9.8 times that prior to the intervention. 93.1% (108/116) of the patients incorporated into the treatment of MDR-TB received the standardized initial chemotherapy program, and the number was 7 times that before the intervention. The referral rates after hospital discharge raised from 0% before the intervention to 92.8% after (90/97) the intervention; and 85.7% (83/97) of the patients received treatment and management by CDC. When the 6-month injection ended, MDR-TB patients still under treatment after the intervention were 84.5% (82/97), and those whose sputum culture became negative were 56.7% (55/97). The proportion of patients with self-paid and with catastrophic expenditures after the intervention were reduced to 18.0% (1 678/9 324) and 44.7% (17/38) respectively, as compared to 75.4% (7 659/10 158) and 76.7% (23/30) respectively before the intervention. To establish a well-performed Hospital-CDC cooperation mechanism could promote the performance of MDR-TB case detection and treatment.

BackgroundThe advent of all-oral regimens for the management of multi-drug resistant tuberculosis (MDR-TB) makes the implementation of community-based directly observed therapy (CB-DOT) a possibility for this group of patients. We set out to determine patient preferences for different attributes of a community-based model for the management of MDR-TB in Uganda.MethodsThe study was conducted at five tertiary referral hospitals. We used a parallel convergent mixed methods study design. To collect quantitative data, we conducted a discrete choice experiment (DCE) with three different attributes of community-based care (DOT provider, location of care, and type of support) combined into eight choice sets, each with two options and an opt-out. We elicited patient reasons for selection of each choice set using qualitative methods. We fitted a mixed logit choice model to determine patient preferences for different attributes of community-based care and estimated the relative importance of each attribute using the range method. and used deductive thematic analysis to understand the reasons for the choices made.ResultsFrom December 2019 to January 2020, we interviewed 103 patients with MDR-TB. We found that all the three attributes considered were important predicators of choice. The relative importance of each attribute was as follows; the type of additional support (relative importance 36.2%), the location of treatment delivery (33.5%), and the type of DOT provider (30.3%). Participants significantly valued treatment delivered by community health workers (CHWs) or expert clients over that delivered by a family member, treatment delivered at home over that delivered at the workplace, and monthly travel vouchers as the form of additional support over phone call or SMS reminders. Subgroup analyses showed significant differences in preference across HIV status, age groups and duration on MDR-TB treatment, but not across gender.The preferred model consisted of a CHW giving DOT at home and travel vouchers to enable attendance of monthly clinic follow-up visits to tertiary referral hospitals for treatment monitoring. Qualitative interviews revealed that patients perceived CHWs as knowledgeable and able to offer psychosocial support. Patients also preferred to take medication at home to save both time and money and lower the risk of facing TB stigma.ConclusionPeople with MDR-TB prefer to be supported to take their medicine at home by a member of their community. The effectiveness of this model of care is being further evaluated.

BACKGROUNDThe guidelines on chemotherapy and management of tuberculosis in the United Kingdom have been reviewed and updated.METHODSA subcommittee was appointed by the Joint Tuberculosis Committee (JTC) of the British Thoracic...

Background: The review of the literature on the diagnosis and management of multidrug-resistant tuberculosis (MDR-TB) reveals a pressing global health challenge characterized by complex factors influencing its prevalence and treatment. (Chhabra et al., 2012) lay the groundwork by identifying systemic issues such as inadequate healthcare resources and poor case detection as significant contributors to the MDR-TB epidemic. Literature Review: (J. Sloan & M. Lewis, 2016) further contribute to the discourse by exploring novel treatments and their applicability in low-resource environments. They emphasize the importance of improved diagnostics and the integration of new therapeutic strategies, while also addressing the financial barriers associated with MDR-TB treatment. (Kolloli & Subbian, 2017) shift the focus to host-directed therapies, arguing for innovative management strategies to address the complexities introduced by co-infections and chronic illnesses. They call for a reevaluation of traditional treatment regimens, particularly for patients with MDR- and extensively drug-resistant tuberculosis (XDR-TB), highlighting the need for approaches that enhance effectiveness. (Yadav, 2023) reviews recent advancements in MDR-TB research, particularly in diagnostic technologies and treatment methodologies. The article reinforces the urgency of addressing the global challenge posed by MDR-TB through innovative strategies that facilitate faster and more accurate diagnosis, ultimately aiming for improved patient outcomes. Conclusion: In conclusion, the literature collectively illustrates the dynamic and intricate landscape of MDR-TB management. The articles underscore the critical need for continued research, enhanced diagnostics, and innovative treatment strategies to effectively combat this growing public health crisis. A multifaceted approach that includes international collaboration, financial investment, and the integration of new technologies is essential for addressing the challenges posed by MDR-TB and improving patient outcomes.

From 1991 until the end of 1998, the number of patients with tuberculosis in Latvia increased 2.5 times with a simultaneous increase of drug resistant and multidrug resistant tuberculosis (MDR-TB). Descriptive analysis of different TB programme services, activities and strategies including Directly Observed Therapy Short-course (DOTS) for tuberculosis and treatment of MDR-TB, were performed. Data from the state tuberculosis registry, drug resistance surveillance, and the national MDR-TB database were used. The state-funded national tuberculosis control programme (NTAP, Nacionâlâ Tuberkulozes Apkarodanas Programma), based on WHO recommended DOTS strategy, was introduced in Latvia in 1996. The NTAP includes TB control in prisons. Treatment of MDR-TB using second line drugs was started in 1997. Cure rates for TB patients increased from 59.5% in 1996 to 77.5% in 2003. Between 1996 and 2003, more than 200 patients began MDR-TB treatment each year, and the cure rate was between 66% and 73%. Numbers of MDR-TB patients were reduced by more than half during this period. Treatment results including MDR-TB reached the WHO target, with cure rates 85% of newly diagnosed patients. These results demonstrate that MDR-TB treatment and management using the individualised treatment approach can be effectively provided within the overall TB programme on a national scale, to successfully treat a large number of MDR-TB patients. Rapid diagnostic methods combined with early intensified case finding, isolation and infection control measures could decrease transmission of TB and MDR-TB in hospitals and in the community. Highly important that MDR-TB management follows WHO recommendations in order to stop creating drug resistance to first and to second line drugs.

Ocular tuberculosis: diagnostic and treatment challenges

Disseminated extrapulmonary MDRTB in a patient with systemic lupus erythematosus initially masquerading as drug-susceptible tuberculosis

Challenging the management of drug-resistant tuberculosis

Tuberculosis (TB) is a serious public health problem in developing countries such as Pakistan. Rapid diagnosis of TB and detection of drug resistance are very important for timely and appropriate management of multidrug-resistant TB (MDR-TB). The purpose of this study was to determine the diagnostic efficacy of the Xpert MTB/RIF assay for rapid diagnosis of TB and detection of rifampicin (RIF) resistance in extrapulmonary and smear-negative pulmonary TB suspects. A total of 98 bronchoalveolar lavage fluid (BALF) and 168 extrapulmonary specimens were processed by Xpert MTB/RIF. Culture results are considered as the gold standard for diagnosis of TB, and drug susceptibility testing for detection of RIF resistance. Diagnostic efficacy was measured in terms of sensitivity, specificity and positive and negative predictive values. The Xpert MTB/RIF assay detected 40 (40.8 %) of 98 BALF of presumptive pulmonary TB and 60 (35.7 %) of 168 extrapulmonary specimens. Sensitivity and specificity of the Xpert MTB/RIF assay for detection of TB was 86 and 88.4 %, respectively. The positive predictive value was 71.5 % while negative predictive value was 95.1 %. The Xpert MTB/RIF assay is a rapid and simple technique with high sensitivity and specificity for diagnosing TB and detecting drug resistance in extrapulmonary and smear-negative TB cases.

Characterization of embB mutations involved in ethambutol resistance in multi-drug resistant Mycobacterium tuberculosis isolates in Zambia

Study DesignRetrospective study.PurposeTo report the prevalence of patients with multidrug-resistant (MDR) tubercular spondylodiscitis and their outcomes. Additionally, to assess the role of Xpert MTB/RIF assay in early detection of MDR tuberculosis. Overview of LiteratureMDR tuberculosis is increasing globally. The World Health Organization (WHO) has strongly recommended Xpert MTB/RIF assay for early detection of tuberculosis.MethodsFrom 2006 to 2015, a retrospective study was conducted on patients treated for MDR tuberculosis of the spine. Only patients whose diagnosis was confirmed using either culture and/or the Xpert MTB/RIF assay were included. Diagnostic method, treatment regimen, time taken to initiate second-line antituberculosis treatment (ATT), drug-related complications, and cost of medications were analyzed. All patients with MDR were treated according to the WHO recommendations for 2 years. The outcome parameters analyzed included clinical, biochemical, and radiological criteria to assess healing status.ResultsFrom 2006 to 2015, a total of 730 patients were treated for tubercular spondylodiscitis. Of those, 36 had MDR tubercular spondylitis (prevalence, 4.9%), and three had extremely drug resistant tubercular spondylitis (prevalence, 0.4%). In this study, 30 patients, with a mean age of 29 years and a mean post-treatment follow-up of 24 months, were enrolled. The majority (77%) had secondary MDR, 17 (56%) underwent surgery, and 26 (87%) completed treatment for 2 years and were healed. Drug-related complications (33%) included ototoxicity, hypothyroidism, and hyperpigmentation of the skin. The average time taken for initiation of second line ATT for MDR patients with Xpert MTB/RIF assay as the diagnostic tool was 18 days, when compared to patients for whom the assay was not available which was 243 days.ConclusionsThe prevalence of MDR tubercular spondylodiscitis was 4.9%. In total, 87% of patients were healed with adequate treatment. The sensitivity and specificity of the Xpert MTB/RIF assay to detect MDR was 100% and 92.3%, respectively.

Background:In sub Saharan Africa, the cocktail of many advanced HIV-infected susceptible hosts, poor TB treatment success rates, a lack of airborne infection control, limited drug-resistance testing (DST) have resulted in HIV-infected individuals being disproportionately represented in Multi drug resistant Tuberculosis (MDR-TB) cases. The prevailing application of the WHO re-treatment protocol indiscriminately to all re-treatment cases sets the stage for an increase in mortality and MDR-TB nosocomial transmission.Method:A comprehensive search was performed of the Cochrane Infectious Diseases Group Specialized Register and Medline database including the bibliographies of the retrieved reference.Findings:The TB diagnosis paradigm which for decades relied on smear sputum and culture is likely to change with the advent of the point-of-care diagnostic, Xpert MTB/RIF assay. Until the new DST infrastructure is available, along with clinical trials for both, current and new approaches to retreatment TB in areas heavily affected by HIV and TB, there are cost effective administrative, environmental, and protective measures that may be immediately instituted.Conclusion:The severe lack of infection control practices in sub Saharan Africa may jeopardise the recent strides in MDR-TB management. Cost effective infection control measures must be immediately implemented, otherwise the development of further drug resistance may offset recent strides in MDR-TB management.Indiscriminate use of the WHO standardized retreatment protocol can lead to nosocomial transmission of MDR-TB by:-Precluding early diagnosis and prompt separation of patients who experienced treatment failure category and thereby more likely to have MDR-TB.-Leaving patients from the treatment failure category in health establishments on ineffective standard retreatment regimen until the DST results are known.-Targeting only patients who have had prior TB therapy, new severely debilitated TB patients having primary unrecognized MDR-TB may continue spreading resistant organisms.

India contributes a quarter of the global burden of multidrug-resistant tuberculosis (MDR-TB) and has inadequate diagnostic infrastructure and institutional capacities for drug susceptibility testing. Subsequently, this leads to a large...

BACKGROUND:Global tuberculosis (TB) epidemic is being driven to an increasing extent by the emergence and spread of drug-resistant strains of Mycobacterium tuberculosis complex (MTBC). We present a case of primary multidrug-resistant tuberculosis (MDR-TB), highlighting Macedonian MDR-TB management issues.CASE REPORT:A 39-year old previously healthy Caucasian male, with no previous history of TB or close contact to TB, was admitted in referral TB-hospital due to respiratory bleeding. Chest X-ray revealed opacity with cavernous lesions in the right upper lobe. Sputum samples showed no presence of acid-fast bacilli (AFB) on fluorescence microscopy, but molecular tests (real-time PCR-based assay and multiplex PCR-based reverse hybridisation Line Probe Assay) confirmed the presence of MTBC, also revealing rifampicin and isoniazid resistance and absence of resistance to second-line anti-tubercular drugs. The strain was considered multidrug-resistant, lately confirmed by conventional methods in liquid and solid culture. Following the protocol of the World Health Organization, we started the longer treatment of MDR-TB comprised of at least five effective anti-tubercular drugs. Due to patient’s extreme non-adherence, we had to delay and modify the regimen (i.e. omitting parenteral aminoglycoside) and to discharge him from the hospital a month after directly observed therapy (DOT) in negative pressure room. As there is no legal remedy in our country regarding involuntary isolation, our patient continued the regimen under ambulatory control of referral TB-hospital. Ignoring the risk of additional acquisition of drug resistance and prolonged exposure of the community to MDR-TB strain - for which he was repeatedly advised - he decided to cease the therapy six months after beginning.CONCLUSION:The benefit of molecular tests in the early diagnosis of TB and drug resistance is unequivocal for adequate treatment of resistant forms of TB. Whole genome sequencing ensures additional knowledge of circulating strains and their resistance patterns. These are essentials of effective TB control programs and can provide evidence to medical and legal authorities for more active policies of screening, involuntary confinement and compliance with therapy, and alternative modalities for successful treatment, as a part of infection control.