Levofloxacin based non‐rifampicin anti‐tuberculous therapy: An effective alternative in renal transplant recipients in resource limited setting

Abstract

Introduction Rifampicin is one of the most effective components of anti‐tuberculous therapy (ATT). Since rifampicin is a hepatic enzyme (CYP3A4) inducer, in a post‐renal transplant recipient, the dose of calcineurin inhibitors needs to be up‐regulated and frequently monitored. In resource‐limited (low‐ and lower‐middle‐income countries) setting this is not always feasible. Therefore, we evaluated a non‐rifampicin‐based ATT using levofloxacin in kidney transplant recipients. Methods We retrospectively studied the medical records of renal transplant recipients diagnosed with tuberculosis in our institute between 2014 and 2017. After a brief discussion with patients regarding the nature and course of ATT, those who opted for a non‐rifampicin based therapy due to financial constraints were included in the study and followed for a minimum of 6 months period after the completion of ATT. Results Out of the 550 renal transplant recipients, 67 (12.2%) developed tuberculosis after a median period of 24 (1‐228) months following transplantation, of them, 64 patients opted for non‐rifampicin‐based ATT. The mean age was 37.6 years. Only 25% were given anti‐thymocyte globulin based induction, while the majority (56; 87.5%) of them were on tacrolimus‐based triple‐drug maintenance therapy. Extrapulmonary tuberculosis was noted in 33% of cases, while 12 (18.7%) had disseminated disease. The median duration of treatment was 12 months and the cure rate of 93.7% (n = 60) was achieved at the end of therapy. Conclusion Levofloxacin based ATT appears to be a safe and effective alternative of rifampicin in kidney transplant recipients who cannot afford heightened tacrolimus dosage.

Real-world experience of adverse reactions-necessitated rifampicin-sparing treatment for drug-susceptible pulmonary tuberculosis

“…In another study, Gupta and colleagues studied renal transplant patients who received rifampicin-sparing treatment. 26 The study showed favorable responses in 60 of 67 (93.7%) patients after a median treatment time of 12 months, and one patient experienced recurrence.…”

Kidney transplantation in patients on anti‐tubercular therapy: A single centre observational study

“…21 Fluoroquinolonebased regimens have been used in solid organ transplant recipients diagnosed with TB with excellent results. [20][21][22] Although one of our patients received ofloxacin, the newer generation fluoroquinolones (moxifloxacin, gatifloxacin, and levofloxacin) have better efficacy 23,24 in the treatment of TB and hence should be preferred agents for transplant recipients with TB. We used a 4-drug rifampicin containing intensive phase ATT pre-transplantation with a fluoroquinolone-based continuation phase ATT post-transplantation.…”

South Asian Transplant Infectious Disease Guidelines for Solid Organ Transplant Candidates, Recipients, and Donors

“…A number of observational studies from SA have shown the efficacy of a regime in which RIF is replaced with fluoroquinolone. 11,22,30 If possible, patients should receive the standard 4-drug treatment (including RIF); however, RIF is a potent inducer of cytochrome A 450 and can lead to a marked reduction in the levels of CNIs, thus increasing the risk of acute rejections in 30% of cases and graft loss in 20%. 14 The interaction is sometimes unpredictable, and it can reduce the CNI levels by 2 to 5 times.…”

“…A recent study from India used a levofloxacin-based regimen (without RIF) in their patients after transplant, and they were successful in full remission in >90% of patients. 22…”