Hepatitis C virus co-infection increases the risk of anti-tuberculosis drug-induced hepatotoxicity among patients with pulmonary tuberculosis.

BACKGROUND: The country of Georgia has a high prevalence of tuberculosis (TB) and hepatitis C virus (HCV) infection. PURPOSE: To determine whether HCV co-infection increases the risk of incident drug-induced hepatitis among patients on first-line anti-TB drug therapy. METHODS: Prospective cohort study; HCV serology was obtained on all study subjects at the time of TB diagnosis; hepatic enzyme tests (serum alanine aminotransferase [ALT] activity) were obtained at baseline and monthly during treatment. RESULTS: Among 326 study patients with culture-confirmed TB, 68 (21%) were HCV co-infected, 14 (4.3%) had chronic hepatitis B virus (HBV) infection (hepatitis B virus surface antigen positive [HBsAg+]), and 6 (1.8%) were HIV co-infected. Overall, 19% of TB patients developed mild to moderate incident hepatotoxicity. In multi-variable analysis, HCV co-infection (adjusted Hazards Ratio [aHR]=3.2, 95% CI=1.6-6.5) was found to be an independent risk factor for incident anti-TB drug-induced hepatotoxicity. Survival analysis showed that HCV co-infected patients developed hepatitis more quickly compared to HCV seronegative patients with TB. CONCLUSION: A high prevalence of HCV co-infection was found among patients with TB in Georgia. Drug-induced hepatotoxicity was significantly associated with HCV co-infection but severe drug-induced hepatotoxicity (WHO grade III or IV) was rare.

Over the Counter Availability of Antituberculosis Drugs in Tbilisi, Georgia in the Setting of a High Prevalence of MDR-TB

Georgia, a country of 4.5 million people, has a high incidence of tuberculosis (TB) including drug resistant cases. Easy access and inappropriate use of anti-TB drugs are risk factors for further development of multidrug resistant (MDR)-TB. We carried out an investigation to assess the availability of over the counter anti-TB agents in pharmacies in Tbilisi. During February 2006, 15 pharmacies were randomly selected and the pharmacist at each store was interviewed. We found that all anti-TB medications stocked by these pharmacies were available and sold without a prescription. All 15 pharmacies sold isoniazid, rifampicin, and streptomycin; 13 (87%) of 15 pharmacies also sold pyrazinamide, ethambutol. Second line anti-TB drugs such as amikacin and kanamycin (injectable agents) and older fluoroquinolones (ofloxacin and ciprofloxacin) were available at 13 pharmacies while newer generation fluoroquinolones were less available(3 sold leovofloxacin, none sold moxifloxacin). The ease access and availability of anti-TB agents is of a great concern given the high prevalence of TB including MDR-TB in Georgia. The potential for misuse of these anti-TB drugs can lead to the development of further drug resistance. These drugs should only be available by prescription in order to reduce the chance of amplifying drug resistance.

High prevalence of multidrug-resistant tuberculosis in Georgia.

BACKGROUND: Tuberculosis (TB) has emerged as a serious public health problem in the country of Georgia. However, little or no data exist on rates and risk factors for drug-resistant TB, including multidrug-resistant (MDR)-TB, in Georgia. OBJECTIVE: To assess the prevalence and risk factors for drug-resistant TB. METHODS: A cross-sectional prospective survey of patients with suspected pulmonary TB was carried out at four sentinel sites (Tbilisi, Zugdidi, Kutaisi, and Batumi) in Georgia between January 1, 2001 and December 31, 2004. RESULTS: Among 1422 patients with suspected pulmonary TB, 996 (70.0%) were culture positive; 931/996 (93.5%) had drug susceptibility testing performed. Overall, 64.0% of patients (48.3% of new and 85.3% of retreatment cases) had positive cultures for Mycobacterium tuberculosis resistant to >or=1 first-line antituberculosis drugs. The overall prevalence of MDR-TB was 28.1% (10.5% of newly diagnosed patients and 53.1% of retreatment cases). In multivariate analysis, risk factors for MDR-TB included: being a retreatment case (prevalence ratio (PR)=5.28, 95% CI 3.95-7.07), history of injection drug use (PR=1.59, 95% CI 1.21-2.09), and female gender (PR=1.36, 95% CI 1.12-1.65). CONCLUSIONS: MDR-TB has emerged as a serious public health problem in Georgia and will greatly impact TB control strategies.