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Major Challenges in Clinical Management of TB/HIV Coinfected Patients in Eastern Europe Compared with Western Europe and Latin America.

Efsen AM, Schultze A, Post FA, Panteleev A, Furrer H, Miller RF, Losso MH, Toibaro J, Skrahin A, Miro JM, Caylà JA, Girardi E, Bruyand M, Obel N, Podlekareva DN, Lundgren JD, Mocroft A, Kirk O, TB:HIV study group in EuroCoo - PLoS ONE (2015)

Bottom Line: Rates of TB/HIV coinfection and multi-drug resistant (MDR)-TB are increasing in Eastern Europe (EE).Between January 1, 2011, and December 31, 2013, 1413 TB/HIV patients (62 clinics in 19 countries in EE, WE, Southern Europe (SE), and LA) were enrolled.Among 585 patients with drug susceptibility test (DST) results, the empiric (i.e. without knowledge of the DST results) anti-TB treatment included ≥3 active drugs in 66% of participants in EE compared with 90-96% in other regions (p<0.0001).

View Article: PubMed Central - PubMed

Affiliation: Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, CHIP, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.

ABSTRACT

Objectives: Rates of TB/HIV coinfection and multi-drug resistant (MDR)-TB are increasing in Eastern Europe (EE). We aimed to study clinical characteristics, factors associated with MDR-TB and predicted activity of empiric anti-TB treatment at time of TB diagnosis among TB/HIV coinfected patients in EE, Western Europe (WE) and Latin America (LA).

Design and methods: Between January 1, 2011, and December 31, 2013, 1413 TB/HIV patients (62 clinics in 19 countries in EE, WE, Southern Europe (SE), and LA) were enrolled.

Results: Significant differences were observed between EE (N = 844), WE (N = 152), SE (N = 164), and LA (N = 253) in the proportion of patients with a definite TB diagnosis (47%, 71%, 72% and 40%, p<0.0001), MDR-TB (40%, 5%, 3% and 15%, p<0.0001), and use of combination antiretroviral therapy (cART) (17%, 40%, 44% and 35%, p<0.0001). Injecting drug use (adjusted OR (aOR) = 2.03 (95% CI 1.00-4.09), prior anti-TB treatment (3.42 (1.88-6.22)), and living in EE (7.19 (3.28-15.78)) were associated with MDR-TB. Among 585 patients with drug susceptibility test (DST) results, the empiric (i.e. without knowledge of the DST results) anti-TB treatment included ≥3 active drugs in 66% of participants in EE compared with 90-96% in other regions (p<0.0001).

Conclusions: In EE, TB/HIV patients were less likely to receive a definite TB diagnosis, more likely to house MDR-TB and commonly received empiric anti-TB treatment with reduced activity. Improved management of TB/HIV patients in EE requires better access to TB diagnostics including DSTs, empiric anti-TB therapy directed at both susceptible and MDR-TB, and more widespread use of cART.

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Factors associated with MDR-TB in multivariable logistic regression analysis.
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pone.0145380.g001: Factors associated with MDR-TB in multivariable logistic regression analysis.

Mentions: The TB diagnosis was definite in approximately half of all patients, and the empiric anti-TB treatment contained RHZ in 78%. In both EE and LA, fewer patients had a definite TB diagnosis (47% and 40%, respectively, vs. 71% and 72% in WE and SE, respectively) and fewer patients in EE received empiric RHZ-containing anti-TB regimens (Table 2). Overall, 569 patients (40% of all patients, 79% of those with definite TB) had anti-TB DST performed within one month of baseline. The proportion of patients with definite TB who had DST performed was lower in EE (73% vs. 83–89%), and the prevalence of R or H resistance and MDR-TB was notably higher in EE (41%, 51% and 40%, respectively, of those tested) compared with other European regions (<10%). In LA, relatively high rates of R or H resistance and MDR-TB were encountered (18%, 25% and 15%, respectively, of those tested). The proportion of patients with no documented resistance was lower in EE (43%) compared with 89–91% in WE and SE and 74% in LA. In both EE and LA, less than half of Mtb isolates were tested for pyrazinamide and ethambutol resistance, and streptomycin resistance was widespread (Table 2). Of the 97 documented MDR-TB cases in EE, 27 (39.1% of 69 tested) were also resistant to kanamycin, amikacin, or capreomycin, 18 (27.7% of 65 tested) to fluoroquinolones, and 7 (14.3% of 49 tested) were XDR-TB. In multivariable models, receiving care in EE (aOR 7.2 [95% CI 3.3–15.8]), prior anti-TB treatment (aOR 3.4 [95% CI 1.9–6.2]) and history of IDU (aOR 2.0 [1.0–4.1]) were all significantly associated with MDR-TB (Fig 1).


Major Challenges in Clinical Management of TB/HIV Coinfected Patients in Eastern Europe Compared with Western Europe and Latin America.

Efsen AM, Schultze A, Post FA, Panteleev A, Furrer H, Miller RF, Losso MH, Toibaro J, Skrahin A, Miro JM, Caylà JA, Girardi E, Bruyand M, Obel N, Podlekareva DN, Lundgren JD, Mocroft A, Kirk O, TB:HIV study group in EuroCoo - PLoS ONE (2015)

Factors associated with MDR-TB in multivariable logistic regression analysis.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4696866&req=5

pone.0145380.g001: Factors associated with MDR-TB in multivariable logistic regression analysis.
Mentions: The TB diagnosis was definite in approximately half of all patients, and the empiric anti-TB treatment contained RHZ in 78%. In both EE and LA, fewer patients had a definite TB diagnosis (47% and 40%, respectively, vs. 71% and 72% in WE and SE, respectively) and fewer patients in EE received empiric RHZ-containing anti-TB regimens (Table 2). Overall, 569 patients (40% of all patients, 79% of those with definite TB) had anti-TB DST performed within one month of baseline. The proportion of patients with definite TB who had DST performed was lower in EE (73% vs. 83–89%), and the prevalence of R or H resistance and MDR-TB was notably higher in EE (41%, 51% and 40%, respectively, of those tested) compared with other European regions (<10%). In LA, relatively high rates of R or H resistance and MDR-TB were encountered (18%, 25% and 15%, respectively, of those tested). The proportion of patients with no documented resistance was lower in EE (43%) compared with 89–91% in WE and SE and 74% in LA. In both EE and LA, less than half of Mtb isolates were tested for pyrazinamide and ethambutol resistance, and streptomycin resistance was widespread (Table 2). Of the 97 documented MDR-TB cases in EE, 27 (39.1% of 69 tested) were also resistant to kanamycin, amikacin, or capreomycin, 18 (27.7% of 65 tested) to fluoroquinolones, and 7 (14.3% of 49 tested) were XDR-TB. In multivariable models, receiving care in EE (aOR 7.2 [95% CI 3.3–15.8]), prior anti-TB treatment (aOR 3.4 [95% CI 1.9–6.2]) and history of IDU (aOR 2.0 [1.0–4.1]) were all significantly associated with MDR-TB (Fig 1).

Bottom Line: Rates of TB/HIV coinfection and multi-drug resistant (MDR)-TB are increasing in Eastern Europe (EE).Between January 1, 2011, and December 31, 2013, 1413 TB/HIV patients (62 clinics in 19 countries in EE, WE, Southern Europe (SE), and LA) were enrolled.Among 585 patients with drug susceptibility test (DST) results, the empiric (i.e. without knowledge of the DST results) anti-TB treatment included ≥3 active drugs in 66% of participants in EE compared with 90-96% in other regions (p<0.0001).

View Article: PubMed Central - PubMed

Affiliation: Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, CHIP, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.

ABSTRACT

Objectives: Rates of TB/HIV coinfection and multi-drug resistant (MDR)-TB are increasing in Eastern Europe (EE). We aimed to study clinical characteristics, factors associated with MDR-TB and predicted activity of empiric anti-TB treatment at time of TB diagnosis among TB/HIV coinfected patients in EE, Western Europe (WE) and Latin America (LA).

Design and methods: Between January 1, 2011, and December 31, 2013, 1413 TB/HIV patients (62 clinics in 19 countries in EE, WE, Southern Europe (SE), and LA) were enrolled.

Results: Significant differences were observed between EE (N = 844), WE (N = 152), SE (N = 164), and LA (N = 253) in the proportion of patients with a definite TB diagnosis (47%, 71%, 72% and 40%, p<0.0001), MDR-TB (40%, 5%, 3% and 15%, p<0.0001), and use of combination antiretroviral therapy (cART) (17%, 40%, 44% and 35%, p<0.0001). Injecting drug use (adjusted OR (aOR) = 2.03 (95% CI 1.00-4.09), prior anti-TB treatment (3.42 (1.88-6.22)), and living in EE (7.19 (3.28-15.78)) were associated with MDR-TB. Among 585 patients with drug susceptibility test (DST) results, the empiric (i.e. without knowledge of the DST results) anti-TB treatment included ≥3 active drugs in 66% of participants in EE compared with 90-96% in other regions (p<0.0001).

Conclusions: In EE, TB/HIV patients were less likely to receive a definite TB diagnosis, more likely to house MDR-TB and commonly received empiric anti-TB treatment with reduced activity. Improved management of TB/HIV patients in EE requires better access to TB diagnostics including DSTs, empiric anti-TB therapy directed at both susceptible and MDR-TB, and more widespread use of cART.

Show MeSH
Related in: MedlinePlus