Time to initiation of multidrug‐resistant tuberculosis treatment and its relation with outcome in a high incidence district in <scp>L</scp>ima, <scp>P</scp>eru

Otero, Larissa; Orbegoso, A. De; Navarro, Alexandra; Ríos, Julia; Parraga, Tommy; Gotuzzo, Eduardo; Seas, Carlos; Stuyft, Patrick Van der

doi:10.1111/tmi.12430

Cited by 5 publications

(5 citation statements)

References 8 publications

(8 reference statements)

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“…Although the full text review failed to deliver any publications fulfilling the inclusion criteria it was noted that a number of articles reported less well defined data on treatment delay (without a 28 day cut-off) related to some interim outcome measures (smear and culture conversion) and final treatment outcomes [ 11 , 13 , 22 , 31 , 37 , 38 , 45 , 46 , 48 , 50 , 51 , 61 , 63 , 64 , 66 , 68 ].…”

Section: Resultsmentioning

confidence: 99%

“…Groups differed in many ways – post implementation group had more HCV co-infection, more initial inpatient treatment, more likely to receive kanamycin instead of capreomycin, higher rates on prior MDR treatment, resistant to more drugs. Pre-implementation 83.9 (56–106) Post-implementation 18.2 (11–24) p<0.01 (Unclear if overall or just for subset who received first line drugs) 12 wk culture conversion Pre-implementation 5/68 (7%) Post-implementation 25/51 (49%) 24 week culture conversion Pre-implementation 43/68 (63%) Post-implementation 44/51 (86%) p=0.01 24 week smear conversion Pre-implementation 77% Post-implementation 90% p=0.05 Li [ 51 ] Lancet Global Health 2015 Programme implementation Median [IQR] time to treatment Time to treatment only reported for 32% and 71% of pre- and post-intervention patients Before 139 [69–207] After 14 [10–21] Still on treatment at 6 months Before 8% (2/26) After 80% (137/172) Loveday [ 11 ] IJTLD 2015 Median (IQR) treatment delay in days Includes all of Loveday 2012 data plus data for 7 additional months Decentralised 72 (54–97) (n=724) Decentralised 72 (54–97) (n=724) Centralised 92 (69–120) (n=811) p<0.001 Treatment success Decentralised 427/736 (58%) Centralised 439/813 (54%) p=0.18 Death Decentralised 133/736 (18.1%) Centralised 113/813 (13.9%) p=0.21 Otero [ 22 ...…”

Section: Resultsmentioning

confidence: 99%

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The effect of early versus late treatment initiation after diagnosis on the outcomes of patients treated for multidrug-resistant tuberculosis: a systematic review

et al. 2016

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BackgroundGlobally it is estimated that 480 000 people developed multidrug-resistant tuberculosis (MDR-TB) in 2014 and 190 000 people died from the disease. Successful treatment outcomes are achieved in only 50 % of patients with MDR-TB, compared to 86 % for drug susceptible disease. It is widely held that delay in time to initiation of treatment for MDR-TB is an important predictor of treatment outcome. The objective of this review was to assess the existing evidence on the outcomes of multidrug- and extensively drug-resistant tuberculosis patients treated early (≤4 weeks) versus late (>4 weeks) after diagnosis of drug resistance.MethodsEight sources providing access to 17 globally representative electronic health care databases, indexes, sources of evidence-based reviews and grey literature were searched using terms incorporating time to treatment and MDR-TB. Two-stage sifting in duplicate was employed to assess studies against pre-specified inclusion and exclusion criteria. Only those articles reporting WHO-defined treatment outcomes were considered for inclusion. Articles reporting on fewer than 10 patients, published before 1990, or without a comparison of outcomes in patient groups experiencing different delays to treatment initiation were excluded.ResultsThe initial search yielded 1978 references, of which 1475 unique references remained after removal of duplicates and 28 articles published pre-1990. After title and abstract sifting, 64 papers underwent full text review. None of these articles fulfilled the criteria for inclusion in the review.ConclusionsWhilst there is an inherent logic in the theory that treatment delay will lead to poorer treatment outcomes, no published evidence was identified in this systematic review to support this hypothesis. Reports of programmatic changes leading to reductions in treatment delay exist in the literature, but attribution of differences in outcomes specifically to treatment delay is confounded by other contemporaneous changes. Further primary research on this question is not considered a high priority use of limited resources, though where data are available, improved reporting of outcomes by time to treatment should be encouraged.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1524-0) contains supplementary material, which is available to authorized users.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

The effect of early versus late treatment initiation after diagnosis on the outcomes of patients treated for multidrug-resistant tuberculosis: a systematic review

et al. 2016

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“…The fact that MDR strains clustered with strains that were resistant to isoniazid or rifampin supports this hypothesis of acquired MDR in retreated cases, which potentially remained infectious for extended periods if not diagnosed properly and treated appropriately. In Peru, the time to change from the standard schedule to the MDR-TB schedule varies from 28 days for new TB patients with risk factors to 2 months for patients without risk factors (61). Second, transmission could have occurred prior to our sampling period.…”

Section: Total 754mentioning

confidence: 99%

Predominant Mycobacterium tuberculosis Families and High Rates of Recent Transmission among New Cases Are Not Associated with Primary Multidrug Resistance in Lima, Peru

et al. 2015

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T uberculosis (TB) is among the top 10 causes of death in the global ranking (1). Although Peru accounts for only 3% of the population of the Americas, it has 9.5% of the region's TB cases. According to the World Health Organization (WHO), 21,916 new cases of pulmonary TB were reported in Peru between January and November 2013 (2). Urban areas are more affected, with 59% of all Peruvian TB cases, 82% of multidrug-resistant (MDR) TB cases, and 93% of extensively drug-resistant (XDR) TB cases occurring in Lima. Within the capital area, TB cases are heterogeneously distributed. The most affected districts are located in the northeast and together represent 86% of the reported cases in the capital (3, 4). San Juan de Lurigancho is the most populated district in this area, with 1,004,339 inhabitants (5), and reports a pulmonary TB incidence rate of 193 cases per 100,000 inhabitants, a smear-positive TB incidence rate of 126 cases per 100,000 inhabitants (6), and an overall MDR prevalence of 7% (7), exceeding the national averages for the three indicators of 103 cases per 100,000 inhabitants, 62 cases per 100,000 inhabitants, and 5.3%, respectively (8). The HIV prevalence among TB patients in this setting is similar to the national prevalence, which in 2008 was 2.6% (9).Peru has been considered a good example of the beneficial effects of implementing directly observed therapy short course (DOTS) in a country's health system (10). Nevertheless, national surveys from 1996 and 2006 have shown increases in MDR rates from 2.4% to 5.3% among new cases and from 15.7% to 23.6% among previously treated cases (11). This paradox of improved TB management and worsening resistance prevalence has been explained by increases in the notified cases, i.e., in case detection, although treatment outcomes remain poor (12). Basically, the observed increases in MDR-TB rates may result from two factors, i.e., transmission of MDR-TB and acquired resistance due to ineffective TB treatment selecting for spontaneous mutations in specific genes associated with drug resistance (13,14).Molecular strain typing (genotyping) has significantly contributed worldwide to the understanding of TB epidemiology and transmission dynamics (15,16), by confirming outbreaks (17) and identifying the clonal spread of successful strains, including MDR strains (18,19). Furthermore, molecular typing has shown that the Mycobacterium tuberculosis complex (MTBc) has a diverse population structure, being composed of seven lineages of human

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“…Patients and HCPs reported structural issues. A number of patients described difficulties accessing treatment, including the financial cost and distance to clinic, which is known to have a detrimental impact on outcomes for MDR-TB [15, 20, 21, 53, 65]. A resource poor health system, as in Iquitos, has been shown to adversely affect patient outcomes [15, 20, 24, 26, 66].…”

Section: Discussionmentioning

confidence: 99%

Improving outcomes for multi-drug-resistant tuberculosis in the Peruvian Amazon – a qualitative study exploring the experiences and perceptions of patients and healthcare professionals

McNally

Wildt

Meza

et al. 2019

BMC Health Serv Res

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Background Management for multi-drug-resistant tuberculosis (MDR-TB) is challenging and has poor patient outcomes. Peru has a high burden of MDR-TB. The Loreto region in the Peruvian Amazon is worst affected for reasons including high rates of poverty and poor healthcare access. Current evidence identifies factors that influence MDR-TB medication adherence, but there is limited understanding of the patient and healthcare professional (HCP) perspective, the HCP-patient relationship and other factors that influence outcomes. A qualitative investigation was conducted to explore and compare the experiences and perceptions of MDR-TB patients and their dedicated HCPs to inform future management strategies. Method Twenty-six, semi-structured in-depth interviews were conducted with 15 MDR-TB patients and 11 HCPs who were purposively recruited from 4 of the worst affected districts of Iquitos (capital of the Loreto region). Field notes and transcripts of the two groups were analysed separately using thematic content analysis. Ethics approval was received from the Institutional Research Ethics Committee, Department of Health, Loreto, and the University of Birmingham Internal Research Ethics Committee. Results Four key themes influencing patient outcomes emerged in each participant group: personal patient factors, external factors, clinical factors, and the HCP-patient relationship. Personal factors included high standard patient and population knowledge and education, which can facilitate engagement with treatment by encouraging belief in evidence-based medicine, dispelling belief in natural medicines, health myths and stigma. External factors included the adverse effect of the financial impact of MDR-TB on patients and their families. An open, trusting and strong HCP-patient relationship emerged as a vitally important clinical factor influencing of patient outcomes. The results also provide valuable insight into the dynamic of the relationship and ways in which a good relationship can be fostered. Conclusions This study highlights the importance of financial support for patients, effective MDR-TB education and the role of the HCP-patient relationship. These findings add to the existing evidence base and provide insight into care improvements and policy changes that could improve outcomes if prioritised by local and national government. Electronic supplementary material The online version of this article (10.1186/s12913-019-4429-y) contains supplementary material, which is available to authorized users.

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Time to initiation of multidrug‐resistant tuberculosis treatment and its relation with outcome in a high incidence district in Lima, Peru

Abstract: We determined the time to start MDR-TB treatment. Time from the first positive smear to MDR-TB treatment was >30 days in 35% (13/37) of patients. Also in 27% (24/88) of patients switched to MDR-TB treatment, time from the last dose of a drug susceptible regimen was > 30 days.

Cited by 5 publications

References 8 publications

The effect of early versus late treatment initiation after diagnosis on the outcomes of patients treated for multidrug-resistant tuberculosis: a systematic review

The effect of early versus late treatment initiation after diagnosis on the outcomes of patients treated for multidrug-resistant tuberculosis: a systematic review

Predominant Mycobacterium tuberculosis Families and High Rates of Recent Transmission among New Cases Are Not Associated with Primary Multidrug Resistance in Lima, Peru

Improving outcomes for multi-drug-resistant tuberculosis in the Peruvian Amazon – a qualitative study exploring the experiences and perceptions of patients and healthcare professionals

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