Tuberculosis Patient-Centred Care

Increasing complexity of tuberculosis (TB) is one of the causes that TB is still the leading cause of death by an infectious disease. Among the complicating factors are increasing drug resistance and comorbidities. Patient-centred care, and even more individualised treatment, would be the way forward. The different aspects of patient-centred care model, including medical, social and supportive care are discussed.</p

Tuberculosis Patient-Centred Care

Increasing complexity of tuberculosis (TB) is one of the causes that TB is still the leading cause of death by an infectious disease. Among the complicating factors are increasing drug resistance and comorbidities. Patient-centred care, and even more individualised treatment, would be the way forward. The different aspects of patient-centred care model, including medical, social and supportive care are discussed.</p

Clinical standards for drug-susceptible pulmonary TB

BACKGROUND: The aim of these clinical standards is to provide guidance on 'best practice´ for diagnosis, treatment and management of drug-susceptible pulmonary TB (PTB). METHODS: A panel of 54 global experts in the field of TB care, public health, microbiology, and pharmacology were identified; 46 participated in a Delphi process. A 5-point Likert scale was used to score draft standards. The final document represents the broad consensus and was approved by all 46 participants. RESULTS: Seven clinical standards were defined: Standard 1, all patients (adult or child) who have symptoms and signs compatible with PTB should undergo investigations to reach a diagnosis; Standard 2, adequate bacteriological tests should be conducted to exclude drug-resistant TB; Standard 3, an appropriate regimen recommended by WHO and national guidelines for the treatment of PTB should be identified; Standard 4, health education and counselling should be provided for each patient starting treatment; Standard 5, treatment monitoring should be conducted to assess adherence, follow patient progress, identify and manage adverse events, and detect development of resistance; Standard 6, a recommended series of patient examinations should be performed at the end of treatment; Standard 7, necessary public health actions should be conducted for each patient. We also identified priorities for future research into PTB. CONCLUSION: These consensus-based clinical standards will help to improve patient care by guiding clinicians and programme managers in planning and implementation of locally appropriate measures for optimal person-centred treatment for PTB.CONTEXTE : L’objectif de ces normes cliniques est de fournir des conseils sur les ‘‘meilleures pratiques’’ en matière de diagnostic, de traitement et de prise en charge de la tuberculose pulmonaire (PTB) pharmacosensible. MÉTHODES : Un panel de 54 experts mondiaux dans le domaine des soins antituberculeux, de la santé publique, de la microbiologie et de la pharmacologie a été identifié ; 46 ont participé à un processus Delphi. Une échelle de Likert en 5 points a été utilisée pour noter les projets de normes. Le document final représente le large consensus et a été approuvé par les 46 participants. RÉSULTATS : Sept normes cliniques ont été définies : Norme 1, tous les patients (adultes ou enfants) qui présentent des symptômes et des signes compatibles avec une PTB doivent subir des examens pour parvenir a un diagnostic ; Norme 2, des tests bactériologiques adéquats doivent être effectués pour exclure une TB résistante aux médicaments ; Norme 3, un régime convenable recommandé par l’OMS et les directives nationales pour le traitement de la PTB doit être identifié ; Norme 4, une éducation et des conseils sur la santé doivent être dispensés à chaque patient commençant le traitement ; Norme 5, un suivi du traitement doit être effectué pour évaluer l’adhésion, suivre les progrès du patient, identifier et gérer les effets indésirables et détecter le développement de la résistance ; Norme 6, une série recommandée d’examens du patient doit être effectuée à la fin du traitement ; Norme 7, les actions de santé publique nécessaires doivent être menées pour chaque patient. Nous avons également identifié les priorités pour les recherches futures sur la PTB. CONCLUSION : Ces normes cliniques consensuelles contribueront á améliorer la prise en charge des patients en guidant les cliniciens et les responsables de programmes dans la planification et la mise en œuvre de mesures localement appropriées pour un traitement optimal de la PTB centré sur la personne

Treatment of Highly Drug-Resistant Pulmonary Tuberculosis

BACKGROUND Patients with highly drug-resistant forms of tuberculosis have limited treatment options and historically have had poor outcomes. METHODS In an open-label, single-group study in which follow-up is ongoing at three South African sites, we investigated treatment with three oral drugs - bedaquiline, pretomanid, and linezolid - that have bactericidal activity against tuberculosis and to which there is little preexisting resistance. We evaluated the safety and efficacy of the drug combination for 26 weeks in patients with extensively drug-resistant tuberculosis and patients with multidrug-resistant tuberculosis that was not responsive to treatment or for which a second-line regimen had been discontinued because of side effects. The primary end point was the incidence of an unfavorable outcome, defined as treatment failure (bacteriologic or clinical) or relapse during follow-up, which continued until 6 months after the end of treatment. Patients were classified as having a favorable outcome at 6 months if they had resolution of clinical disease, a negative culture status, and had not already been classified as having had an unfavorable outcome. Other efficacy end points and safety were also evaluated. RESULTS A total of 109 patients were enrolled in the study and were included in the evaluation of efficacy and safety end points. At 6 months after the end of treatment in the intention-to-treat analysis, 11 patients (10%) had an unfavorable outcome and 98 patients (90%; 95% confidence interval, 83 to 95) had a favorable outcome. The 11 unfavorable outcomes were 7 deaths (6 during treatment and 1 from an unknown cause during follow-up), 1 withdrawal of consent during treatment, 2 relapses during follow-up, and 1 loss to follow-up. The expected linezolid toxic effects of peripheral neuropathy (occurring in 81% of patients) and myelosuppression (48%), although common, were manageable, often leading to dose reductions or interruptions in treatment with linezolid. CONCLUSIONS The combination of bedaquiline, pretomanid, and linezolid led to a favorable outcome at 6 months after the end of therapy in a high percentage of patients with highly drug-resistant forms of tuberculosis; some associated toxic effects were observed. (Funded by the TB Alliance and others; ClinicalTrials.gov number, NCT02333799.)

Role of therapeutic drug monitoring in pulmonary infections : use and potential for expanded use of dried blood spot samples

Respiratory tract infections are among the most common infections in men. We reviewed literature to document their pharmacological treatments, and the extent to which therapeutic drug monitoring (TDM) is needed during treatment. We subsequently examined potential use of dried blood spots as sample procedure for TDM. TDM was found to be an important component of clinical care for many (but not all) pulmonary infections. For gentamicin, linezolid, voriconazole and posaconazole dried blood spot methods and their use in TDM were already evident in literature. For glycopeptides, beta-lactam antibiotics and fluoroquinolones it was determined that development of a dried blood spot (DBS) method could be useful. This review identifies specific antibiotics for which development of DBS methods could support the optimization of treatment of pulmonary infections

The pharmacokinetics of antibiotics in cystic fibrosis

Introduction Dosing of antibiotics in people with cystic fibrosis (CF) is challenging, due to altered pharmacokinetics, difficulty of lung tissue penetration, and increasing presence of antimicrobial resistance. Areas covered The purpose of this work is to critically review original data as well as previous reviews and guidelines on pharmacokinetics of systemic and inhaled antibiotics in CF, with the aim to propose strategies for optimization of antibacterial therapy in both children and adults with CF. Expert opinion For systemic antibiotics, absorption is comparable in CF patients and non-CF controls. The volume of distribution (Vd) of most antibiotics is similar between people with CF with normal body composition and healthy individuals. However, there are a few exceptions, like cefotiam and tobramycin. Many antibiotic class-dependent changes in drug metabolism and excretion are reported, with an increased total body clearance for ss-lactam antibiotics, aminoglycosides, fluoroquinolones, and trimethoprim. We, therefore, recommend following class-specific guidelines for CF, mostly resulting in higher dosages per kg bodyweight in CF compared to non-CF controls. Higher local antibiotic concentrations in the airways can be obtained by inhalation therapy, with which eradication of bacteria may be achieved while minimizing systemic exposure and risk of toxicity