Abstract
BackgroundWhile the high burden of multidrug-resistant tuberculosis (MDR-TB) itself is a matter of great concern, the emergence and rise of advanced forms of drug-resistance such as extensively drug-resistant TB (XDR-TB) and extremely drug-resistant TB (XXDR-TB) is more troubling. The aim of this study was to investigate the trends over time of patterns of drug resistance in a sample of MDR-TB patients in greater metropolitan Mumbai, India.MethodsThis was a retrospective, observational study of drug susceptibility testing (DST) results among MDR-TB patients from eight health care facilities in greater Mumbai between 2005 and 2013. We classified resistance patterns into four categories: MDR-TB, pre-XDR-TB, XDR-TB and XXDR-TB.ResultsA total of 340 MDR-TB patients were included in the study. Pre-XDR-TB was the most common form of drug-resistant TB observed overall in this Mumbai population at 56.8% compared to 29.4% for MDR-TB. The proportion of patients with MDR-TB was 39.4% in the period 2005–2007 and 27.8% in 2011–2013, while the proportion of those with XDR-TB and XXDR-TB was changed from 6.1% and 0% respectively to 10.6% and 5.6% during the same time period. During the same periods, the proportions of patients with ofloxacin, moxifloxacin and ethionamide resistance significantly increased from 57.6% to 75.3%, from 60.0% to 69.5% and from 24.2% to 52.5% respectively (p<0.05).DiscussionThe observed trends in TB drug-resistance patterns in Mumbai highlight the need for individualized drug regimens, designed on the basis of DST results involving first- and second-line anti-TB drugs and treatment history of the patient. A drug-resistant TB case-finding strategy based on molecular techniques that identify only rifampicin resistance will lead to initiation of suboptimal treatment regimens for a significant number of patients, which may in turn contribute to amplification of resistance and transmission of strains with increasingly advanced resistance within the community.
Highlights
India has one of the highest burdens of multidrug-resistant tuberculosis (MDR-TB) globally, with an estimated 64,000 patients having MDR strains among notified pulmonary TB cases in 2013, which would account for more than 20 percent of the estimated global burden of drugresistant tuberculosis [1]
Pre-XDR-TB was the most common form of drug-resistant TB observed overall in this Mumbai population at 56.8% compared to 29.4% for MDR-TB
The proportion of patients with MDR-TB was 39.4% in the period 2005–2007 and 27.8% in 2011–2013, while the proportion of those with XDR-TB and XXDR-TB was changed from 6.1% and 0% respectively to 10.6% and 5.6% during the same time period
Summary
India has one of the highest burdens of multidrug-resistant tuberculosis (MDR-TB) globally, with an estimated 64,000 patients having MDR strains among notified pulmonary TB cases in 2013, which would account for more than 20 percent of the estimated global burden of drugresistant tuberculosis [1]. The overall magnitude of the MDR-TB epidemic in Mumbai, one of the most known Indian mega-cities, is increasingly being documented. D’Souza et al in 2009 reported epidemic levels of drug resistance amongst new TB cases in central Mumbai [5]. In late 2014, a survey among HIV-infected patients in the greater metropolitan Mumbai reported both alarming levels of drug-resistant tuberculosis among new and previously treated TB cases, as well as complex resistance patterns, especially high levels of resistance to fluoroquinolones and other second line anti-TB drugs [14]. The aim of this study was to investigate the trends over time of patterns of drug resistance in a sample of MDR-TB patients in greater metropolitan Mumbai, India
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