Treatment Outcome and Mortality among Patients with Multidrug-resistant Tuberculosis in Tuberculosis Hospitals of the Public Sector

This study was conducted to evaluate treatment outcome, mortality, and predictors of both in patients with multidrug-resistant tuberculosis (MDR-TB) at 3 TB referral hospitals in the public sector of Korea. We included MDR-TB patients treated at 3 TB referral hospitals in 2004 and reviewed retrospectively their medical records and mortality data. Of 202 MDR-TB patients, 75 (37.1%) had treatment success and 127 (62.9%) poor outcomes. Default rate was high (37.1%, 75/202), comprising 59.1% of poor outcomes. Male sex (adjusted odds ratio [aOR], 2.91; 95% confidence interval [CI], 1.13-7.49), positive smear at treatment initiation (aOR, 5.50; 95% CI, 1.22-24.90), and extensively drug-resistant TB (aOR, 10.72; 95% CI, 1.23-93.64) were independent predictors of poor outcome. The all-cause mortality rate was 31.2% (63/202) during the 3-4 yr after treatment initiation. In conclusion, the treatment outcomes of patients with MDR-TB at the 3 TB hospitals are poor, which may reflect the current status of MDR-TB in the public sector of Korea. A more comprehensive program against MDR-TB needs to be integrated into the National Tuberculosis Program of Korea.

Treatment Outcome and Mortality among Patients with Multidrug-resistant Tuberculosis in Tuberculosis Hospitals of the Public Sector

This study was conducted to evaluate treatment outcome, mortality, and predictors of both in patients with multidrug-resistant tuberculosis (MDR-TB) at 3 TB referral hospitals in the public sector of Korea. We included MDR-TB patients treated at 3 TB referral hospitals in 2004 and reviewed retrospectively their medical records and mortality data. Of 202 MDR-TB patients, 75 (37.1%) had treatment success and 127 (62.9%) poor outcomes. Default rate was high (37.1%, 75/202), comprising 59.1% of poor outcomes. Male sex (adjusted odds ratio [aOR], 2.91; 95% confidence interval [CI], 1.13-7.49), positive smear at treatment initiation (aOR, 5.50; 95% CI, 1.22-24.90), and extensively drug-resistant TB (aOR, 10.72; 95% CI, 1.23-93.64) were independent predictors of poor outcome. The all-cause mortality rate was 31.2% (63/202) during the 3-4 yr after treatment initiation. In conclusion, the treatment outcomes of patients with MDR-TB at the 3 TB hospitals are poor, which may reflect the current status of MDR-TB in the public sector of Korea. A more comprehensive program against MDR-TB needs to be integrated into the National Tuberculosis Program of Korea.

The actual condition of drug-resistant tuberculosis and treatment outcomes at a tuberculosis specialized hospital / 대한내과학회지

BACKGROUND: During the last decade, the reports of drug-resistant tuberculosis in Korea were not common. Therefore, we investigated the anti-tuberculosis drug resistance rate according to medical history and radiological findings, as well as the relationship between the drug resistance and treatment outcomes to provide guidelines for selection of drug regimen before drug sensitivity test. METHODS: The study population was composed of 745 hospitalized patients who received drug susceptibility test for M. tuberculosis and anti-tuberculosis chemotherapy for the last 5 years. RESULTS: The majority had resistance to at least one drug (91.3%; 3.8+/-2.6 drugs). Drug resistance rate of first line drugs was 25~55%; especially higher in retreatment cases and those with the cavity on chest X-ray. Drug resistance was not correlated with radiographic finding. The success rate for treatment was higher in new cases, patients with less severe disease status and those without cavity on chest X-ray. When new cases had no resistance to all of EHR (84.1%), the negative conversion rate by first line drugs was above 70~90%. For retreatment patients, the negative conversion rate was above 70% only when they were susceptible to all of EHR (31%). The relapse rate was 4~13%. CONCLUSIONS: Probably the prevalence of drug-resistant tuberculosis in Korea will be considerably high. The drug resistance and treatment outcome was affected more by history of previous medical treatment than radiological findings. The previous EHRZ regimen is very effective as the initial treatment in new case, but revised retreatment regimen composed of at least 4 drugs is needed in the previously treated patients.

The survey for clinical course of intractable pulmonary tuberculosis / 대한내과학회지

BACKGROUND: Although various standard anti-tuberculosis chemotherapy regimens were suggested by World Health Organization in pulmonary tuberculosis, as yet, treatment regimen has not been established in intractable pulmonary tuberculosis. Also those surveys for intractable pulmonary tuberculosis were few. Therefore, the purpose of this study is to investigate the clinical course of radiological finding and pulmonary function pattern in intractable pulmonary tuberculosis, to assess the factors that affect the fate and so to make some suggestions for the management of intractable pulmonary tuberculosis. METHODS: This study population was composed of 40 patients with culture-proven pulmonary tuberculosis hospitalized. Although all 40 patients were received regular standard anti-tuberculosis chemotherapy which was individualized on the basis of susceptibility results, all patients were chronic excretors of mycobacterium tuberculosis bacilli (chronics), whose sputum cultures tested positive at both 11 and 12 months after admission. RESULTS: The rate of male and female was about 6:1 and mean age was 47.8+/-14.6 years old. Resistance to most of anti-tuberculosis drugs was observed and especially high degree resistance of isoniazid (95%), rifampicin (92.5%), ethambutol (87.5%), prothionamide and ofloxacin was found. Irrespective of the type of anti-tuberculosis chemotherapy and use of sensitive drug, clinical course was not significantly changed. On the pulmonary function test, most represented restrictive (57.5%) or combined pattern (27.5%) and had no significant interval change. Also arterial blood gas analysis finding was not changed. On chest X-ray findings, 80% had cavitary lesions, 87.5% showed far advanced stage and most (85%) had no significant interval change. However, 15% has changed to aggravation state, which had high frequency in patient with more than 3 susceptible drugs and significant decrease of FEV1 and FEV1/FVC on pulmonary function test findings that did not affect the mortality. The mortality rate was 30%, the average interval from diagnosis to death was 30.6+/-20.3 months and the fate was not associated with radiological findings, arterial blood gas analysis findings and pulmonary function test findings but only body weight at diagnosis of intractable pulmonary tuberculosis. CONCLUSIONS: The clinical course of intractable pulmonary tuberculosis that had no specific treatment did not depend on radiological findings and pulmonary function test findings but nutrition state at diagnosis. Therefore, in addition to anti-tuberculosis treatment, intractable pulmonary tuberculosis patient is recommended to be received aggressive conservative treatment that focuses on nutrition balance. Also it is probably essential to prevent the spread of intractable pulmonary tuberculosis to healthy person.

The effect of diabetes mellitus on treatment outcomes in pulmonary tuberculosis / 대한내과학회지

BACKGROUN: Many studies have shown that diabetes mellitus does not modify the clinical features and treatment outcomes. However, to our knowledge, those surveys for clinical features and treatment outcomes in pulmonary tuberculosis with diabetics were performed 15 years ago and have not been confirmed by more recent reports. Therefore, the purpose of this study is to investigate the effect of diabetes mellitus on microbiologic findings in far advanced stage of pulmonary tuberculosis and so to make some suggestions for the management of pulmonary tuberculosis with diabetes mellitus. METHODS: This study population was composed of 47 patients with far advanced stage of culture-proven pulmonary tuberculosis hospitalized in our department from 2000 through 2002. None of patients was intractable. Patients were divided into 4 groups; group1;nondiabetics with initial treatment, group2;diabetics with initial treatment, group3;nondiabetics with retreatment, group4; diabetics with retreatment. Treatment regimens were individualized on the basis of susceptibility results. A retrospective review of the records of all 47 patients with pulmonary tuberculosis and diabetes mellitus was carried out. The clinical features, bacteriologic, radiographic findings and treatment outcomes were compared among 4 groups. RESULTS: Time to negative conversion of AFB in sputum smear was significantly increased in diabetics group than nondiabetics, but time to negative conversion of AFB in sputum culture was not significant. Also time to negative conversion of AFB in sputum smear or culture was not affected by treatment pattern. The effect of antituberculosis medication significantly delayed response in diabetics with retreatment and resistance rate was higher in diabetics or retreatment. Time to negative conversion of AFB in sputum smear was related to cavitary size in radiographic findings, but time to negative conversion of AFB in sputum culture was related to drug sensitivity. Natural course of cavity on radiographic findings after antituberculosis therapy was not significant. CONCLUSION: It seems that diabetes mellitus does not affect bacteriological negative conversion rates except negative conversion rate of AFB in sputum smear, which chiefly related to cavitary size, in far advanced stage of pulmonary tuberculosis. Therefore, because the presence of AFB in sputum smear after 5th months of therapy is not necessarily a treatment failure in far advanced stage of pulmonary tuberculosis with diabetics, any decision regarding prologation or change in therapy maybe required based on the results of culture and drug susceptibility tests.

Dysregulated Production of IFN-g, IL-12, and IL-10 by Peripheral Blood Mononuclear Cells from Early Active Pulmonary and Multidrug-Resistant Tuberculosis Patients

In this study, we investigated profiles of the cytokines IFN-g, IL-12, and IL-10 in active pulmonary tuberculosis (EAPTB) patients, HIV-negative patients with multidrug-resistant tuberculosis (MDR-TB) and in healthy tuberculin reactors (HTR). We studied the responses of peripheral blood mononuclear cells (PBMC) from 12 EAPTB patients and 15 MDR-TB patients to stimulation with a purified protein derivatives (PPD) antigen (Ag), and compared them with those from 14 HTR. Using ELISA, IFN-g production was found to be significantly depressed, while IL-10 was significantly elevated in both MDR-TB and EAPTB after in vitro stimulation with PPD, compared with those in HTR. Although there was no significant difference in IL-12 production among the three groups, mean IL-12 production was highest in patients with MDR-TB. In these patients, IL-12 production was significantly correlated with IL-10 expression, but not IFN-g production. In addition, neutralization of endogenous IL-10 led to enhanced IFN-g and IL-12Rb2 mRNA expression in TB patients. Our findings suggest that both groups of TB patients may have a similar disregulated pattern of IL-12, IL-10, and IFN-g production during M. tuberculosis infection. Furthermore, the results suggest a potentially pathogenic role for IL-10 in impaired Th1 immune responses in TB patients.

Depression of Both Interferon-gamma and Tumor Necrosis Factor-alpha Production by Peripheral Blood Mononuclear Cells from Chronic Refractory Tuberculosis Patients

Understanding human immune responses in chronic refractory tuberculosis (CRTB) is important for developing immunotherapy against the disease. The aim of this study was to examine cytokine responses [interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and IL-10] by peripheral blood mononuclear cells (PBMCs) in CRTB patients after in vitro stimulation with the 30-kDa or purified protein derivative (PPD) antigen (Ag). Most of the CRTB cases were multidrug-resistant (MDR) TB. The results were compared with those from early TB (E-TB) patients and healthy tuberculin reactors (HTR). IFN-gamma production was significantly depressed in both CRTB and E-TB groups compared with HTR. In response to the 30-kDa Ag, TNF-alpha levels were significantly depressed only in CRTB patients, while greatly increased in E-TB patients. In addition, IL-10 production was significantly increased in E-TB patients, and PBMC from both E-TB and CRTB patients secreted more IL-6 than HTR. IL-10 neutralization significantly increased TNF-alpha levels, whereas anti-TNF-alpha did not alter IL-10 induction significantly in PBMC from HTR and CRTB patients. Our findings suggest that CRTB patients have depression in both IFN-gamma and TNF-alpha reponses, which might play important roles during chronic M. tuberculosis infection.

The Clinical Characteristics of Initial Drug Resistance in MDR-TB Patients / 결핵

BACKGROUND: Multidrug-resistant tuberculosis(MDR-TB) in patients is mainly caused by acquired drug resistance, However, a small proportion of MDR-TB is caused by initial drug resistance(IDR), which may be somewhat different from acquired drug resistance. This study analyzed the clinical characteristics of IDR in MDR-TB patients to use the results as basic data in managing the disease. METHODS: A retrospective study of 30 IDR cases in MDR-TB patients from Jan. 1995 to Dec. 1998 was perormed. In order to analyzed the clinical charcteristics, the age, sex, family history, duration of negative conversion, number of resistant drugs, treatment regimens, duration of treatment, extent of disease and cavitary lesion on the chest X-ray was examined. In order too analyzed the level of improvement, the extent of the disease and cavitary lesion on the chest X-ray, tested by Wilcoxon signed rank sum test, and the disease free interval rate of 1-year and 4-year was examined using the Kaplan-Meier method. RESULTS: The mean age of the patients was 46.6 years and the sex ratio 1:1. Six(20%) patients had a family history. The mean negative conversin of the sputum AFB stain was 2.6 months. The number of resistant drugs was 7.6 and the number of used drugs 3.6. Twenty-three(67%) patients were treated for less than 12months and 28(93%) patients were treated with first-line drugs. The extent of the disease and the cavitary lesion on the chest X-ray improved after treatment(p<0.05). Among 13 patients who were followed up for 22.6 months, 2(15%) patients relapsed and the disease free interval rate of 1-year and 4-year was 85%. CONCLUSION: It is recommended that the duration of treatment of IDR in MDR-TB with first-line drugs be 9-12 months even if the extent of disease and cavitary lesion on the chest X-ray improves.

Median sternotomy for bilateral resection or plication of bullae / 대한흉부외과학회지

No abstract available.