ABSTRACT
We present the case of a pregnant woman who died from disseminated tuberculosis (TB), and the difficulties encountered in diagnosing TB disease in her newborn. We discuss the burden of maternal and neonatal TB and the need for a different approach, one that is not solely based on bacteriologic evidence which, in most cases, tends to be inconclusive. We also explore the difficulties physicians and national TB programs face in managing and developing effective policies for these two highly vulnerable and neglected populations. There is an urgent need for a more realistic approach to neonatal and infant TB diagnosis.
Subject(s)
Infant, Newborn, Diseases/diagnosis , Pregnancy Complications, Infectious/diagnosis , Tuberculosis/diagnosis , Female , Humans , Infant , Infant, Newborn , Infant, Newborn, Diseases/drug therapy , Infant, Newborn, Diseases/microbiology , Pregnancy , Pregnancy Complications, Infectious/microbiology , Tuberculosis/congenital , Tuberculosis/drug therapyABSTRACT
People living with the human immunodeficiency virus (HIV) (PLHIV) are at high risk for tuberculosis (TB), and TB is a major cause of death in PLHIV. Preventing TB in PLHIV is therefore a key priority. Early initiation of antiretroviral therapy (ART) in asymptomatic PLHIV has a potent TB preventive effect, with even more benefits in those with advanced immunodeficiency. Applying the most recent World Health Organization recommendations that all PLHIV initiate ART regardless of clinical stage or CD4 cell count could provide a considerable TB preventive benefit at the population level in high HIV prevalence settings. Preventive therapy can treat tuberculous infection and prevent new infections during the course of treatment. It is now established that isoniazid preventive therapy (IPT) combined with ART among PLHIV significantly reduces the risk of TB and mortality compared with ART alone, and therefore has huge potential benefits for millions of sufferers. However, despite the evidence, this intervention is not implemented in most low-income countries with high burdens of HIV-associated TB. HIV and TB programme commitment, integration of services, appropriate screening procedures for excluding active TB, reliable drug supplies, patient-centred support to ensure adherence and well-organised follow-up and monitoring that includes drug safety are needed for successful implementation of IPT, and these features would also be needed for future shorter preventive regimens. A holistic approach to TB prevention in PLHIV should also include other important preventive measures, such as the detection and treatment of active TB, particularly among contacts of PLHIV, and control measures for tuberculous infection in health facilities, the homes of index patients and congregate settings.
Subject(s)
Anti-HIV Agents/administration & dosage , Antitubercular Agents/administration & dosage , HIV Infections/epidemiology , Tuberculosis/prevention & control , CD4 Lymphocyte Count , Developing Countries , HIV Infections/complications , HIV Infections/drug therapy , Humans , Isoniazid/administration & dosage , Poverty , Tuberculosis/epidemiologyABSTRACT
SUMMARY
Multidrug-resistant (MDR) and extensively drug-resistant tuberculosis (XDR-TB) are global concerns, with stagnant treatment success rates of roughly 54% and 30%, respectively. Despite adverse events associated with several DR-TB drugs, newly developed drugs and shorter regimens are bringing hope; recent concern has focused on drugs that prolong the corrected QT interval (QTc). QTc prolongation is a risk factor for torsades de pointe (TdP), a potentially lethal cardiac arrhythmia. While QTc prolongation is used in research as a surrogate marker for drug safety, the correlation between QTc and TdP is not perfect and depends on additional risk factors. The electrocardiogram (ECG) monitoring that has been recommended when new drugs are used has created alarm among clinicians and National Tuberculosis Programmes (NTPs). ECG monitoring is often challenging in high-burden settings where treatment alternatives are limited. According to a review of studies, the prevalence of sudden death directly attributable to TdP by QTc-prolonging DR-TB drugs is likely less than 1%. The risk of death from an ineffective MDR-TB/XDR-TB regimen thus far exceeds the risk of death from arrhythmia. In patients with QTc prolongation who develop cardiac events, other significant risk factors in addition to the drugs themselves are nearly always present. Clinicians and NTPs should be aware of and manage all possible circumstances that may trigger an arrhythmia (hypopotassaemia and human immunodeficiency virus infection are probably the most frequent in DR-TB patients). We present the limited but growing evidence on QTc prolongation and DR-TB management and propose a clinical approach to achieve an optimal balance between access to life-saving drugs and patient safety.ABSTRACT
No disponible
Subject(s)
Humans , Vitamin B 12 Deficiency , Vitamin B 12 , Administration, OralABSTRACT
No disponible
