Manejo de los casos en retratamiento de tuberculosis con sospecha de resistencia a fármacos.

The management of patients with resistance to anti tuberculous drugs is complex and therefore must be managed by physician specialists. The most difficult patients are the cases in retreatment, where some very different possibilities are possible, as abandonment, failures and relapses. Patients with multi-drug resistant (MDR) tuberculosis are the most difficult to treat; MDR appears in all the failures or non-adherences to the treatment regime. To elaborate a scheme of retreatment for these patients, two guidelines must be followed: (1) do not rely on outcomes of drug susceptibility tests and (2) a detailed history of drug treatment must be considered of paramount importance. With this information, a retreatment scheme can be formulated that involves the use of at least three drugs not previously taken by the patient. For a successful control of tuberculosis, the national tuberculosis programs in Latin American countries must assure careful management of newly diagnosed patients. Secondly, if resources are available, a bank of second-line drugs must be ready for managing retreatment situations (e.g., 3 Z-Kn-Eth-Of/15 Z-Eth-Of) if first line drug treatments fail. Using individualized retreatment with second line drugs is recommended only in industrialized countries, and for a few middle income countries as a last resort.El manejo de los casos de tuberculosis con sospecha de resistencia a fármacos es bastante complejo por lo que sólo debería realizarse por médicos especialistas expertos. Los más preocupantes son los enfermos en retratamiento, entre cuyas posibilidades se encuentran entidades microbiológicas y operativas tan diferentes como la recaída bacteriológica, el fracaso farmacológico, el abandono y la mala adherencia al tratamiento. Lo auténticamente preocupante es que se puedan dar las condiciones para que se seleccionen resistencias, hecho que ocurre, casi invariablemente, en los fracasos y abandonos parciales de la medicación. Para el manejo de estos enfermos debe tenerse en cuenta el valor limitado de las pruebas de susceptibilidad a fármacos y la importancia de la detallada y dirigida historia de fármacos tomados en el pasado para elaborar una pauta de retratamiento. Con esto y con el conocimiento perfecto de todos los fármacos con acción frente a la tuberculosis, se puede diseñar un esquema de retratamiento que incluya un mínimo de 3-4 fármacos nunca utilizados en el enfermo. Una vez asegurado el buen manejo de los enfermos iniciales, los países con recursos económicos suficientes quizá deberían pensar en adquirir un banco de fármacos de segunda línea para poder ofrecer un esquema de retratamiento estandarizado (3-6 Z-Kn-Eth-Of/15-18 Z-Eth-Of) a los fracasos de los esquemas de primera línea. La posibilidad de un retratamiento individualizado quizá sólo se debería recomendar en los países con altos recursos económicos y, solo excepcionalmente, como última posibilidad en algunos países con recursos económicos medios

Tuberculosis treatment adherence and fatality in Spain

<p>Abstract</p> <p>Background</p> <p>The adherence to long tuberculosis (TB) treatment is a key factor in TB control programs. Always some patients abandon the treatment or die. The objective of this study is to identify factors associated with defaulting from or dying during antituberculosis treatment.</p> <p>Methods</p> <p>Prospective study of a large cohort of TB cases diagnosed during 2006-2007 by 61 members of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR). Predictive factors of completion outcome (cured plus completed treatment vs. defaulters plus lost to follow-up) and fatality (died <it>vs. </it>the rest of patients) were based on logistic regression, calculating odds ratios (OR) and 95% confidence intervals (CI).</p> <p>Results</p> <p>Of the 1490 patients included, 29.7% were foreign-born. The treatment outcomes were: cured 792 (53.2%), completed treatment 540 (36.2%), failure 2 (0.1%), transfer-out 33 (2.2%), default 27 (1.8%), death 27 (1.8%), lost to follow-up 65 (4.4%), other 4 (0.3%). Completion outcome reached 93.5% and poor adherence was associated with: being an immigrant (OR = 2.03; CI:1.06-3.88), living alone (OR = 2.35; CI:1.05-5.26), residents of confined institutions (OR = 4.79; CI:1.74-13.14), previous treatment (OR = 2.93; CI:1.44-5.98), being an injecting drug user (IDU) (OR = 9.51; CI:2.70-33.47) and treatment comprehension difficulties (OR = 2.93; CI:1.44-5.98). Case fatality was 1.8% and it was associated with the following variables: age 50 or over (OR = 10.88; CI:1.12-105.01), retired (OR = 12.26;CI:1.74-86.04), HIV-infected (OR = 9.93; CI:1.48-66.34), comprehension difficulties (OR = 4.07; CI:1.24-13.29), IDU (OR = 23.59; CI:2.46-225.99) and Directly Observed Therapy (DOT) (OR = 3.54; CI:1.07-11.77).</p> <p>Conclusion</p> <p>Immigrants, those living alone, residents of confined institutions, patients treated previously, those with treatment comprehension difficulties, and IDU patients have poor adherence and should be targeted for DOT. To reduce fatality rates, stricter monitoring is required for patients who are retired, HIV-infected, IDU, and those with treatment comprehension difficulties.</p

Multidrug-resistant tuberculosis

The ideal number of drugs needed and treatment duration are crucial issues in the management of multidrug-resistant tuberculosis (MDR-TB). Thus, we read with interest the Article by the Collaborative Group for the Meta-Analysis of Individual Patient Data in MDR-TB treatment–2017,1 the results of which support our proposal,2 from 2015, to classify anti-tuberculosis drugs on the basis of their toxicity, and sterilising or bactericidal activity

Social, Clinical and Microbiological Differential Characteristics of Tuberculosis among Immigrants in Spain

BACKGROUND: To identify the differential tuberculosis (TB) characteristics within the immigrant population with respect to natives in Spain. METHODOLOGY/PRINCIPAL FINDINGS: A prospective cohort study design was implemented to examine the TB cases diagnosed and starting standard antituberculous treatment in Spain, between January 1st 2006 and March 31st 2007. A logistic regression analysis was performed to determine differential characteristics. 1,490 patients were included in the study population, 1,048 natives and 442 (29.7%) immigrants. According to the multivariate analysis, the following variables were significantly associated with immigrant TB cases: younger age (OR = 3.79; CI:2.16-6.62), living in group situation (OR = 7.61; CI:3.38-12.12), lower frequency of disabled (OR:0.08; CI:0.02-0.26) and retired (OR:0.21; CI:0.09-0.48) employment status, lower frequency of pulmonary disease presentation (OR = 0.47; CI:0.24-0.92), primary or emergency care admission (OR = 1.80; CI:1.05-3.06 and OR = 2.16; CI:1.36-3.45), drug resistance (OR = 1.86; CI:1.01-3.46), treatment default (OR:2.12; CI:1.18-3.81), lower frequency of alcohol and cigarette consumption (OR = 2.10; CI:1.42-3.11 and OR = 2.85; CI:2.10-3.87 respectively), more directly observed treatment (OR = 1.68; CI:1.04-2.69), and poor understanding of TB disease and its treatment (OR = 3.11; CI:1.86-5.20). The low percentage of primary MDR-TB in the native population (0.1% vs. 2.2% of immigrants) should be noted. CONCLUSIONS/SIGNIFICANCE: The differences show the need to introduce specific strategies in the management of TB within the immigrant population, including the improvement of social and work conditions

Multidrug-resistant Tuberculosis Management in Resource-limited Settings

Managing MDRTB through national programs can yield results similar to those seen in wealthier settings

Unsuspected and extensive transmission of a drug-susceptible Mycobacterium tuberculosis strain

<p>Abstract</p> <p>Background</p> <p>A large and unsuspected tuberculosis outbreak involving 18.7% of the total of the tuberculosis cases studied, was detected in a population-based molecular epidemiological study performed in Zaragoza (Spain) from 2001 to 2004.</p> <p>Methods</p> <p>The <it>Mycobacterium tuberculosis </it>drug-susceptible strain, named <it>MTZ </it>strain, was genetically characterized by IS<it>6110</it>-RFLP, Spoligotyping and by MIRU-VNTR typing and the genetic patterns obtained were compared with those included in international databases. The characteristics of the affected patients, in an attempt to understand why the <it>MTZ </it>strain was so highly transmitted among the population were also analyzed.</p> <p>Results</p> <p>The genetic profile of the <it>MTZ </it>strain was rare and not widely distributed in our area or elsewhere. The patients affected did not show any notable risk factor for TB.</p> <p>Conclusion</p> <p>The <it>M. tuberculosis </it>strain <it>MTZ</it>, might have particular transmissibility or virulence properties, and we believe that greater focus should be placed on stopping its widespread dissemination.</p

SARS-CoV-2 Infection in Multiple Sclerosis

To understand COVID-19 characteristics in people with multiple sclerosis (MS) and identify high-risk individuals due to their immunocompromised state resulting from the use of disease-modifying treatments. Retrospective and multicenter registry in patients with MS with suspected or confirmed COVID-19 diagnosis and available disease course (mild = ambulatory; severe = hospitalization; and critical = intensive care unit/death). Cases were analyzed for associations between MS characteristics and COVID-19 course and for identifying risk factors for a fatal outcome. Of the 326 patients analyzed, 120 were cases confirmed by real-time PCR, 34 by a serologic test, and 205 were suspected. Sixty-nine patients (21.3%) developed severe infection, 10 (3%) critical, and 7 (2.1%) died. Ambulatory patients were higher in relapsing MS forms, treated with injectables and oral first-line agents, whereas more severe cases were observed in patients on pulsed immunosuppressors and critical cases among patients with no therapy. Severe and critical infections were more likely to affect older males with comorbidities, with progressive MS forms, a longer disease course, and higher disability. Fifteen of 33 patients treated with rituximab were hospitalized. Four deceased patients have progressive MS, 5 were not receiving MS therapy, and 2 were treated (natalizumab and rituximab). Multivariate analysis showed age (OR 1.09, 95% CI, 1.04-1.17) as the only independent risk factor for a fatal outcome. This study has not demonstrated the presumed critical role of MS therapy in the course of COVID-19 but evidenced that people with MS with advanced age and disease, in progressive course, and those who are more disabled have a higher probability of severe and even fatal diseas

Manejo de los casos en retratamiento de tuberculosis con sospecha de resistencia a fármacos.

El manejo de los casos de tuberculosis con sospecha de resistencia a fármacos es bastante complejo por lo que sólo debería realizarse por médicos especialistas expertos. Los más preocupantes son los enfermos en retratamiento, entre cuyas posibilidades se encuentran entidades microbiológicas y operativas tan diferentes como la recaída bacteriológica, el fracaso farmacológico, el abandono y la mala adherencia al tratamiento. Lo auténticamente preocupante es que se puedan dar las condiciones para que se seleccionen resistencias, hecho que ocurre, casi invariablemente, en los fracasos y abandonos parciales de la medicación. Para el manejo de estos enfermos debe tenerse en cuenta el valor limitado de las pruebas de susceptibilidad a fármacos y la importancia de la detallada y dirigida historia de fármacos tomados en el pasado para elaborar una pauta de retratamiento. Con esto y con el conocimiento perfecto de todos los fármacos con acción frente a la tuberculosis, se puede diseñar un esquema de retratamiento que incluya un mínimo de 3-4 fármacos nunca utilizados en el enfermo. Una vez asegurado el buen manejo de los enfermos iniciales, los países con recursos económicos suficientes quizá deberían pensar en adquirir un banco de fármacos de segunda línea para poder ofrecer un esquema de retratamiento estandarizado (3-6 Z-Kn-Eth-Of/15-18 Z-Eth-Of) a los fracasos de los esquemas de primera línea. La posibilidad de un retratamiento individualizado quizá sólo se debería recomendar en los países con altos recursos económicos y, solo excepcionalmente, como última posibilidad en algunos países con recursos económicos medios