Management of Pediatric Contacts of Multidrug Resistant Tuberculosis in the United Kingdom

Abstract

To the Editors: Children exposed to drug-susceptible tuberculosis are less likely to progress to active disease if receiving prophylactic treatment, a practice now recommended by most international guidelines.1,2 Appropriate prophylactic therapy covering multidrug-resistant tuberculosis (MDR-TB) was shown to reduce the risk of progression to MDR-TB disease 5-fold in children who were household contacts of adults with pulmonary MDR-TB.3 No unified guidance currently exists for management of MDR-TB–exposed children.2,4 A retrospective audit of management of MDR-TB–exposed children was conducted as part of a wider survey of management of pediatric MDR-TB in England.5 Data were included if the contact had more than 8 hours of exposure to a household or close social contact with culture-confirmed pulmonary MDR-TB between January 1, 2006, and December 31, 2010. Demographic, diagnostic and management details were collected through questionnaires sent to the lead TB pediatrician at each center. Returned information was collated, and descriptive analyses were carried out using Excel version 97–2003 workbook. There were 23 children in 6 centers in close contact with culture-proven pulmonary MDR-TB. Eight were uninfected, did not receive chemoprophylaxis and to date none has developed disease. Twelve children were identified as latently infected. Eight children (66.6%) received treatment for presumed latent MDR-TB. In all cases 2 drugs were used for a median of 6 months (range 6–12 months). Treatment regimens were selected according to the contacts’ in vitro susceptibility testing. Two children currently remain in follow-up for 2 years. The other 10 children were all well at the time of discharge with no evidence of TB disease. Three children had suspected but not culture-confirmed MDR-TB disease, all of whom had a known parental contact with MDR-TB. All children had sputum samples sent for cultures, but no organism was isolated. The median number of drugs used for treatment was 4 (3–5), and the median planned length of therapy was 18 months (range 12–24). One of the 3 children received an injectable agent. The resistance pattern of the index case did not obviously account for the regimen choice in the children. All children were still being followed at the time of writing, and none are known to be receiving directly observed treatment. Although we have a small dataset, our audit is the first to review the management of pediatric contacts with infectious MDR-TB in England and is the largest dataset from Western Europe and North America published to date. Clinical practice showed considerable variability, and children were less likely to receive prophylactic therapy if there was resistance to several drugs in the index case. Our small dataset cannot provide sufficient evidence for or against treatment for latent TB in MDR-exposed children, but illustrates that many clinicians chose to treat. It will be important to examine the age-related risk of progression to active disease in larger groups of patients and balance these data with the likelihood of adherence, which might be compromised by treatment regimens sometimes more difficult to administer or prone to side-effects. Bhanu Williams, MRCPCH North West London Hospitals NHS Trust Harrow, United Kingdom Shiva Ramroop, MRCPCH Great Ormond Street Hospital Pooja Shah, MBBS Imperial NHS Trust Laura Anderson, PhD Health Protection Agency Sreena Das, MRCPCH Anna Riddell, MRCPCH Susan Liebeschuetz, MRCPCH Barts Health NHS Trust London, United Kingdom Jolanta Bernatoniene, MRCPCH Bristol Royal Hospital for Children Bristol, United Kingdom Delane Shingadia, FRCPCH Great Ormond Street Hospital Beate Kampmann, PhD Imperial College London, United Kingdom MRC Unit The Gambia