Perceived Barriers to Accessing Tuberculosis Care Among Multidrug Resistant Tuberculosis (MDR-TB) Patients: A Qualitative Study in Indonesia

Indonesia has one of the highest MDR-TB burdens in the world. The success rate of MDR-TB treatment in Indonesia is still low. Indonesia changed the health system policy, which is called the National Health Insurance,in 2013. The purpose of this study is to provide a description from the point of view of MDR-TB patients about barriers during their treatment, although the health system in Indonesia has changed. This study used qualitative semi�structured in-depth questions. Fifteen MDR-TB patients were interviewed concerning the barriers during their treatment. Purposive sampling was used to recruit study participants. Thematic analysis was used to identify and analyse the main topics. Topics generated were financial barriers, poor service, inadequate hospital facilities, ineffective communication of patient-provider, stigma, and lack of social support. Each theme was from verbatim transcripts defined during the coding process. Codes and themes were developed to coincide with data collection. Periodic monitoring of aid disbursements, improvement of hospital services including health workers and facilities, increased social support, increased knowledge and home-based MDR-TB service programs can be implemented to reduce the perceived barriers for MDR-TB patients during treatment

The Sustainability Approach to Treatment of DR-TB Patients through Community Social Organization (Aisyiyah)

Multidrug-resistant tuberculosis (MDR-TB) is currently an important public health problem in the world. Treatment of MDR-TB patients takes a long time, 20-24 months in standard regimen or 9-11 months in shorter regimen. Long treatment duration and drug toxicities which higher than drug-sensitive TB can cause drop out of treatment. Aisyiyah is a community social organization which provide assistance to TB patients in order to complete the treatment within specified time period. This study aimed to compare the outcome of DR-TB patients assisted by Aisyiyah and those who did not. A retrospective study was conducted Dr. Soetomo General Academic Hospital, Surabaya, Indonesia. Data was taken from DR-TB patients medical record since October 2014 until December 2017. There were 434 MDR-TB patients in the period of October 2014 to December 2017, with 75 patients (17.28%) received assistance from Aisyiyah. The average age was 44.38 ± 12.28 years old. Comparison between those who were assisted and not, from the male sex (49.3% vs 60.2%), women (50.7% vs 39.8%); based on resistance pattern: (5.3% vs 10.3%) from MDR TB, (85.3% vs 75.5%) from RR, (2.7% vs 8.1%) from XDR; Outcome obtained: Cure (1.6% vs 15.0%; p=0,031), Treatment completion (0.0% vs 0.5%; p=0,517), Default (2.8% vs 28.3%; p=0,002); Failed (0.2% vs 1.6%; p=0,718); Death (1.6% vs 7.9%; p=0,965). There were significant correlations between cure and default outcome in DR-TB patients accompanied by Aisyiyah compared to those not accompanied

Drug-Resistant Tuberculosis: Correlation between Positivity of Acid-Fast Bacilli Sputum and Time to Conversion on Patients with Short-Term Treatment Regimen

Drug-resistant tuberculosis (DR-TB) is a worldwide global burden and related to poor treatment outcomes. Monitoring the progress of DR-TB treatment can be carried out microscopic with Acid-Fast Bacilli (AFB) sputum smear and assessed from the beginning or the first time the patient is diagnosed and monthly to determine the sequential conversion of AFB baseline to the next month twice until it becomes negative. The prolonged conversion has been associated with infectiousness and treatment outcomes. This study was aimed to determine the correlation between positivity of AFB sputum and time to conversion in DR-TB patients with short-term treatment (STR) regimen. An analytic retrospective at hospital collected from medical records of DR-TB patients, from September 2017 to July 2018. Spearman technique was used to analyze the data with p 0.05). AFB sputum have significant correlation with time of culture conversion (p 0.05). There was no significant relation between positivity of AFB baseline and time to sputum conversion in DR-TB patients on short-term treatment (STR) regimen. AFB sputum have significant correlation with time of culture conversion in DR-TB patients on short-term treatment (STR) regimen

A Woman with Tuberculosis Multidrug Resistance and QTc Prolongation Repetitive Interval: A Case Report

Abstract Background : Prolonged QTc interval is one of the side effects of the short-regimen MDR-TB. QTc prolongation is a risk factor for Torsades de pointes and is influenced by many factors. Case : 47-year-old woman who was diagnosed with MDR-TB through GeneXpert examination and received short-regimen MDR-TB. This patient experienced repeated QTc prolongation, with peak QTc interval 600 msec occurring at 4th month with mild hypokalemia without clinical symptoms. The patient completed 9 months of shortregimen therapy with improve chest x ray followed by negative sputum culture. Conclusion : Short-regimen MDR-TB contains several drugs that cause QTc prolongation. Clinical evaluation is required in patients with QTc prolongation before changing the regiment

Nontuberculous mycobacterial species and Mycobacterium tuberculosis complex coinfection in patients with pulmonary tuberculosis in Dr. Soetomo Hospital, Surabaya, Indonesia

Objective/Background: The aim of this study was to analyze the detection of nontuberculous mycobacterial (NTM) species derived from sputum specimens of pulmonary tuberculosis (TB) suspects. Increasing prevalence and incidence of pulmonary infection by NTM species have widely been reported in several countries with geographical variation. Materials and Methods: Between January 2014 and September 2015, sputum specimens from chronic pulmonary TB suspect patients were analyzed. Laboratory examination of mycobacteria was conducted in the TB laboratory, Department of Clinical Microbiology, Dr. Soetomo Hospital, Surabaya. Detection and identification of mycobacteria were performed by the standard culture method using the BACTEC MGIT 960 system (BD) and Lowenstein–Jensen medium. Identification of positive Mycobacterium tuberculosis complex (MTBC) was based on positive acid-fast bacilli microscopic smear, positive niacin accumulation, and positive TB Ag MPT 64 test results (SD Bioline). If the growth of positive cultures and acid-fast bacilli microscopic smear was positive, but niacin accumulation and TB Ag MPT 64 (SD Bioline) results were negative, then the isolates were categorized as NTM species. MTBC isolates were also tested for their sensitivity toward first-line anti-TB drugs, using isoniazid, rifampin, ethambutol, and streptomycin. Results: From 2440 sputum specimens of pulmonary TB suspect patients, 459 isolates (18.81%) were detected as MTBC and 141 (5.78%) as NTM species. Conclusion: From the analyzed sputum specimens, 18.81% were detected as MTBC and 5.78% as NTM species. Each pulmonary TB suspect patient needed clinical settings to suspect causative agents of MTBC and/or NTM species; clinicians have to understand the local epidemiological data for the evaluation of causes of lung infection to determine appropriate therapy

Survival of a Coronavirus Disease-2019 (COVID-19) Patient with Acute Respiratory Distress Syndrome (ARDS) in Dr. Soetomo Hospital, Surabaya, Indonesia

An outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that began in Wuhan, China has spread rapidly in multiple countries of the world and has become a pandemic. Currently, there is no vaccine or specific antiviral for COVID-19. A study reported 7.3% of critical patients admitted to ICU, 71% of them required mechanical ventilation, and 38.5% of them were survived. Herein, we reported a 54 year old man with Acute Respiratory Distress Syndrome (ARDS) of COVID-19 who survived the disease. Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay of nasopharyngeal and oropharingeal swabs were positive for SARS-CoV-2. Diagnosis of ARDS was also according to clinical symptoms, laboratory, chest radiograph, and chest CT scan. Alcaligenes faecalis and Candida albicans were also identified from sputum culture. Treatment for this patient was causal and supportive therapy, including antibiotic, antiviral, and antifungal therapy according to the culture results, fluid resuscitation, and oxygen supply from the mechanical ventilator. This patient was survived and discharged on hospital day-29. A fibrosis in parenchyma pulmonary and sensory peripheral neuropathy occurred after survived from ARDS. Monitoring of clinical, laboratory, and chest radiograph were continued after the patient discharged from the hospital. This case highlights the importance of early diagnosis and effective treatment to the care of COVID-19 patient

Factors that Contribute to the QTc Interval Prolongation in DR-TB Patients on STR Regimen

Abstract Introduction: QTc interval prolongation is one of the adverse drug reaction of several drugs used in DR-TB patients treated with STR regimen. Drug-induced QTc prolongation can predispose patient to develop lifethreatening arrhythmia, increasing hospital length of stay and mortality. This study aims to determine factors that contribute to QTc prolongation in DR-TB patients on STR regimen. Methods. This was an observational retrospective study using medical records of DR-TB patients who received STR regimen from August 2017 to March 2019 in tertiary hospital DR Soetomo, Surabaya, Indonesia. QTc interval was calculated by Fredericia formula. The influence of risk factors (age, body weight (BW), Body Mass Index (BMI), gender, comorbid, potassium, sodium and QTc baseline) with QTc prolongation was analyzed using multiple regression. The relationship between Moxifloxacin dosage and QTc was analyzed using Chi-Square test. Results Out of the 113 DR-TB patients who received the STR therapy regimen, 98 patients were eligible for this study. They consist of 62 (%) male; 36 (%) female. Thirty-five (35,7%) of them had Diabetes Mellitus as a comorbid disease. The mean age of the patients was 44±11 years, with the mean of BMI was 20.20± 3.73. Potassium and Sodium levels at the baseline were 4.192 ± 0.58 and 138.05 ± 4.562 respectively. The QTc baseline before receiving STR regimen was 431.9±30,617ms. Patients received a dose of moxifloxacin 400 mg (5.1%) , 600 mg (59,2%), and 800 mg (35,7%) according to body weight. There were no correlation between age, BW, gender, comorbid, and sodium baseline with QTc. There were correlation between potassium (p=0,001), BMI (p=0,006) and QTc baseline (p <0,001) with QTc. Conclusion QTc baseline and potassium level are factors that contribute to the prolongation of the QTc interval

Moxifloxacin concentration correlate with QTc interval in rifampicin-resistant tuberculosis patients on shorter treatment regimens

Abstract Background: Drug-resistant tuberculosis (DR-TB) continues to be a global threat. Moxifloxacin is one of the components of the shorter treatment regimen which is suspected to increase the risk of QT prolongation, although it is also likely to be the most effective against DR-TB. A study to evaluate the correlation between the concentration of moxifloxacin and QTc interval in RR-TB patients who received shorter regimens is needed. Methods: This was an observational study in 2 groups of RR-TB patients on shorter treatment regimens (intensive phase and continuation phase), contain moxifloxacin with body weight-adjusted dose. Blood samples were collected at 2 h after taking the 48th-hour dose and 1 h before taking the 72nd-hour dose. Results: Forty-five RR-TB patients were included in this study. At 2 h after taking the 48th-hour dose, the mean of QTc interval in intensive phase and continuation phase was 444.38 ms vs. 467.94 ms, p = 0.026, while mean of moxifloxacin concentration in intensive phase and continuation phase was 4.3 µg/mL vs. 4.61 µg/mL, p = 0.686). At 1 h before taking the 72nd-hour dose, both moxifloxacin concentration and QTc interval in intensive phase and continuation showed no significant difference with p-value of 0.610 and 0.325, respectively. At 2 h after taking the 48th-dose, moxifloxacin concentration did not correlate with QTc interval, both in intensive phase (p = 0.576) and in continuation phase (p = 0.691). At 1 h before taking the 72nd-hour dose, moxifloxacin concentration also did not correlate with QTc interval in intensive phase (p = 0.531) and continuation phase (p = 0.209). Conclusions: Our study found that moxifloxacin concentration did not correlate with QTc interval, which indicates the safe use of moxifloxacin on QTc interval. In addition to close monitoring of QTc interval, the clinicians should also consider other variables which potentially increase risk for QTc prolongation in DR-TB patients who received shorter treatment regimens