Frequency and type of microbiological monitoring of multidrug-resistant tuberculosis treatment

Kurbatova EV, Gammino VM, Bayona J, et al. IJTLD 2011; 15(11): 1553-5.

A retrospective analysis of three alternative monitoring strategies in a cohort of MDR-TB patients in Estonia, Latvia, Philippines, Russia and Peru (2000-2004), which illustrates that less frequent testing delays confirmation of bacteriological conversion. The delay prolongs intensive treatment, hospitalization, and respiratory isolation, increasing cost and toxicity. After conversion, less frequent testing could delay diagnosis of possible treatment failure.

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Household contact investigation of multidrug-resistant and extensively drug-resistant tuberculosis in a high HIV prevalence setting.

Vella V, Racalbuto V, Guerra R, et al. IJTLD 2011; 15(9): 1170-5.

A prospective, observational study evaluating adult household contacts for active TB in order to determine the incidence rates of MDR- and XDR-TB of index cases diagnosed between January 2005 and September 2008 in a high HIV prevalnece setting. The authors conclude that active case finding for drug-resistant TB is a high-yield public health activity and must be a priority, as early diagnosis may stem further disease spread and improve survival.

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Identifying multidrug resistant tuberculosis transmission hotspots using routinely collected data.

Manjourides J, Lin HH, Shin S, et al. Tuberculosis (Edinb). 2012;92(3):273-9. Epub 2012 Mar 6.

In most countries with large drug resistant tuberculosis epidemics, only those cases that are at highest risk of having MDRTB receive a drug sensitivity test (DST) at the time of diagnosis. Because of this prioritized testing, identification of MDRTB transmission hotspots in communities where TB cases do not receive DST is challenging, as any observed aggregation of MDRTB may reflect systematic differences in how testing is distributed in communities. We introduce a new disease mapping method, which estimates this missing information through probability-weighted locations, to identify geographic areas of increased risk of MDRTB transmission.

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MSF, PIH, TAG Report (2011): An evaluation of drug-resistant TB treatment scale-up

The report points out that despite international calls to reach universal access to TB treatment by 2015, scale-up has been minimal. Substantial funding and implementation gaps remain at both national and international levels The report aims to provide an assessment of the effectiveness of some key structures within the global response for MDR-TB, to provide recommendations on how the global response to DR-TB scale-up can be improved, and to examine the results of scale-up activities to date in three key countries.

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Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response

A new report on anti-tuberculosis resistance published by the WHO, updating its 2008 report with new and improved data. For the first time, the report includes an assessment of the progress countries are making to diagnose and treat MDR-TB cases. It urges greater investment in infrastructure, diagnostics, and provision of care in order to reach the 2015 target of diagnosing and treating 80% of the estimated M/XDR-TB cases.

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Multidrug-resistant pulmonary tuberculosis treatment regimens and patient outcomes: an individual patient data meta-analysis of 9,153 patients.

Ahuja SD, Ashkin D, Avendano M, Banerjee R, Bauer M, et al. PLoS Med 2012; 9(8): e1001300.

An individual patient data meta-analysis was conducted by this collaborative group to assess the impact on outcomes of the type, number, and duration of drugs used to treat MDR-TB. They used three recent systematic reviews to identify studies reporting treatment outcomes of microbiologically confirmed MDR-TB. The authors of those studies were contacted to solicit individual patient data including clinical characteristics, treatment given, and outcomes. The collaborative group concludes that improved MDR-TB treatment success and survival were associated with use of certain fluoroquinolones, ethionamide, or prothionamide, and greater total number of effective drugs. However, randomized trials are needed to optimize MDR-TB treatment.

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Pediatric Tuberculosis: New Guidelines and Recommendations.

Perez-Velez, C.M. Curr Op Ped 2012; 24(3): 319-28.

This study discussed the recommendations pertaining to infants, children, and adolescents in new and updated TB guidelines that have been published since 2010 – with emphasis on those from supranational organizations. The main developments in the guidelines covered in this article are related to: novel diagnostics for TB infection, disease, and drug resistance; updated treatment regimens for childhood and drug-resistant TB (DR-TB); and primary and secondary prevention of TB disease in HIV-infected children and adolescents.

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Prevalence of and risk factors for resistance to second-line drugs in people with multidrug-resistant tuberculosis in eight countries: a prospective cohort study.

Dalton T, Cegielski P, Akksilp S, et al. Lancet 2012 [epub ahead of print].

The prevalence of extensively drug-resistant (XDR) TB is increasing owing to the expanded use of second-line drugs in people with multidrug-resistant (MDR) TB. The authors prospectively assessed resistance to second-line anti-TB drugs in eight countries. Among 1,278 patients, 43·7% showed resistance to at least one second-line drug, 20·0% to at least one second-line injectable drug, and 12·9% to at least one fluoroquinolone; 6·7% of patients had XDR TB (range across study sites 0·8-15·2%). Previous treatment with second-line drugs was consistently the strongest risk factor for resistance to these drugs, which increased the risk of XDR TB by more than 4 times.

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Report: Rational use of moxifloxacin for tuberculosis treatment

Cox H, Ford N, Keshavjee S, McDermid C, Von Schoen-Angerer T, Mitnick C, Goermaere E. Lancet 2011; 11(4): 259-60.

This article outlines the potential risks of incorporating moxifloxacin into the existing first-line regimen, as it could compromise the efficacy of FQs in DR-TB treatment. The authors recommend reserving moxifloxacin as a second-line drug for the treatment of DR-TB, until potent partner drugs have been developed to make it efficacious as a first-line regimen.

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Scaling up interventions to achieve global tuberculosis control: progress and new developments.

Raviglione M, Marais B, Floyd K, et al. Lancet 2012;379(9829):1902-13.

Tuberculosis is still one of the most important causes of death worldwide. In this update we review recent progress. With improved control efforts, the world and most regions are on track to achieve the Millennium Development Goal of decreasing tuberculosis incidence by 2015, and the Stop TB Partnership target of halving 1990 mortality rates by 2015; the exception is Africa. Despite these advances, full scale-up of tuberculosis and HIV collaborative activities remains challenging and emerging drug-resistant tuberculosis is a major threat. Achievement of international tuberculosis control targets and maintenance of these gains needs optimum national health policies and services, with ongoing investment into new approaches and strategies. Despite growing funding in recent years, a serious shortfall persists. International and national financial uncertainty places gains at serious risk. Perseverance and renewed commitment are needed to achieve global control of tuberculosis, and ultimately, its elimination.

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