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      Treatment and outcomes in children with multidrug-resistant tuberculosis: A systematic review and individual patient data meta-analysis

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      1 , 2 , * , 1 , 3 , 1 , 4 , 5 , 3 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 10 , 15 , 16 , 9 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 18 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 25 , 42 , 43 , 1 , * , for the Collaborative Group for Meta-Analysis of Paediatric Individual Patient Data in MDR-TB
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          Abstract

          Background

          An estimated 32,000 children develop multidrug-resistant tuberculosis (MDR-TB; Mycobacterium tuberculosis resistant to isoniazid and rifampin) each year. Little is known about the optimal treatment for these children.

          Methods and findings

          To inform the pediatric aspects of the revised World Health Organization (WHO) MDR-TB treatment guidelines, we performed a systematic review and individual patient data (IPD) meta-analysis, describing treatment outcomes in children treated for MDR-TB. To identify eligible reports we searched PubMed, LILACS, Embase, The Cochrane Library, PsychINFO, and BioMedCentral databases through 1 October 2014. To identify unpublished data, we reviewed conference abstracts, contacted experts in the field, and requested data through other routes, including at national and international conferences and through organizations working in pediatric MDR-TB. A cohort was eligible for inclusion if it included a minimum of three children (aged <15 years) who were treated for bacteriologically confirmed or clinically diagnosed MDR-TB, and if treatment outcomes were reported. The search yielded 2,772 reports; after review, 33 studies were eligible for inclusion, with IPD provided for 28 of these. All data were from published or unpublished observational cohorts. We analyzed demographic, clinical, and treatment factors as predictors of treatment outcome. In order to obtain adjusted estimates, we used a random-effects multivariable logistic regression (random intercept and random slope, unless specified otherwise) adjusted for the following covariates: age, sex, HIV infection, malnutrition, severe extrapulmonary disease, or the presence of severe disease on chest radiograph. We analyzed data from 975 children from 18 countries; 731 (75%) had bacteriologically confirmed and 244 (25%) had clinically diagnosed MDR-TB. The median age was 7.1 years. Of 910 (93%) children with documented HIV status, 359 (39%) were infected with HIV. When compared to clinically diagnosed patients, children with confirmed MDR-TB were more likely to be older, to be infected with HIV, to be malnourished, and to have severe tuberculosis (TB) on chest radiograph ( p < 0.001 for all characteristics). Overall, 764 of 975 (78%) had a successful treatment outcome at the conclusion of therapy: 548/731 (75%) of confirmed and 216/244 (89%) of clinically diagnosed children (absolute difference 14%, 95% confidence interval [CI] 8%–19%, p < 0.001). Treatment was successful in only 56% of children with bacteriologically confirmed TB who were infected with HIV who did not receive any antiretroviral treatment (ART) during MDR-TB therapy, compared to 82% in children infected with HIV who received ART during MDR-TB therapy (absolute difference 26%, 95% CI 5%–48%, p = 0.006). In children with confirmed MDR-TB, the use of second-line injectable agents and high-dose isoniazid (15–20 mg/kg/day) were associated with treatment success (adjusted odds ratio [aOR] 2.9, 95% CI 1.0–8.3, p = 0.041 and aOR 5.9, 95% CI 1.7–20.5, p = 0.007, respectively). These findings for high-dose isoniazid may have been affected by site effect, as the majority of patients came from Cape Town. Limitations of this study include the difficulty of estimating the treatment effects of individual drugs within multidrug regimens, only observational cohort studies were available for inclusion, and treatment decisions were based on the clinician’s perception of illness, with resulting potential for bias.

          Conclusions

          This study suggests that children respond favorably to MDR-TB treatment. The low success rate in children infected with HIV who did not receive ART during their MDR-TB treatment highlights the need for ART in these children. Our findings of individual drug effects on treatment outcome should be further evaluated.

          Abstract

          In a systematic review and meta-analysis conducted to inform World Health Organization guidelines, Elizabeth Harausz and colleagues investigate different treatment regimens and outcomes for children with multidrug-resistant tuberculosis.

          Author summary

          Why was this study done?
          • Treatment for multidrug-resistant tuberculosis (MDR TB) affects 32,000 children per year, requires longer treatment with much more toxic medications than drug-susceptible tuberculosis. Unfortunately, little is know about the optimal treatment for children with MDR TB.

          • This study reviewed treatment and outcome data from children around the world in order to better understand the management of MDR-TB in children.

          • This study also sought to understand the risk factors for poor treatment outcomes in children with MDR-TB.

          • This study informed the World Health Organization guidelines on treatment of MDR-TB in children.

          What did the researchers do and find?
          • We performed a systematic review and individual patient data meta-analysis on clinical characteristics and treatment outcomes on 975 children from across 18 countries.

          • Children were analyzed in two separate groups, those with bacteriologically confirmed MDR-TB and those who were clinically diagnosed with MDR-TB.

          • We found that, in general, children do well when treated with the second-line MDR-TB medications (78% overall had successful treatment outcomes), despite the fact that there was a high burden of severe disease.

          • Malnutrition and not being treated for HIV (if the child was HIV-positive) during TB treatment significantly increased the risk of poor outcomes.

          • Second-line injectable agents and high-dose isoniazid were associated with treatment success. However, a high proportion of children with non-severe disease who received no second-line injectable agents still did well; therefore, children with non-severe disease may be able to be spared from these toxic medications.

          What do these findings mean?
          • Consideration should be given to using high-dose isoniazid in treatment regimens, and if children have non-severe disease, the possibility of excluding second-line injectable agents from the treatment regimen should be considered.

          • HIV treatment should be started as soon as is possible, and malnutrition should be aggressively treated.

          Related collections

          Most cited references36

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          • Article: not found

          The natural history of childhood intra-thoracic tuberculosis: a critical review of literature from the pre-chemotherapy era.

          The pre-chemotherapy literature documented the natural history of tuberculosis in childhood. These disease descriptions remain invaluable for guiding public health policy and research, as the introduction of effective chemotherapy radically changed the history of disease. Specific high-risk groups were identified. Primary infection before 2 years of age frequently progressed to serious disease within the first 12 months without significant prior symptoms. Primary infection between 2 and 10 years of age rarely progressed to serious disease, and such progression was associated with significant clinical symptoms. In children aged >3 years the presence of symptoms represented a window of opportunity in which to establish a clinical diagnosis before serious disease progression. Primary infection after 10 years of age frequently progressed to adult-type disease. Early effective intervention in this group will reduce the burden of cavitating disease and associated disease transmission in the community. Although the pre-chemotherapy literature excluded the influence of human immune deficiency virus (HIV) infection, recent disease descriptions in HIV-infected children indicate that immune-compromised children behave in a similar fashion to immune immature children (less than 2 years of age). An important concept deduced from the natural history of tuberculosis in childhood is that of relevant disease. Deciding which children to treat may be extremely difficult in high-prevalence, low-resource settings. The concept of relevant disease provides guidance for more effective public health intervention.
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            • Article: not found

            WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update.

            The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥ 20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens.
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              • Abstract: found
              • Article: not found

              Induced sputum versus gastric lavage for microbiological confirmation of pulmonary tuberculosis in infants and young children: a prospective study.

              For microbiological confirmation of diagnosis of pulmonary tuberculosis in young children, sequential gastric lavages are recommended; sputum induction has not been regarded as feasible or useful. We aimed to compare the yield of Mycobacterium tuberculosis from repeated induced sputum with that from gastric lavage in young children from an area with a high rate of HIV and tuberculosis. We studied 250 children aged 1 month to 5 years who were admitted for suspected pulmonary tuberculosis in Cape Town, South Africa. Sputum induction and gastric lavage were done on three consecutive days according to a standard procedure. Specimens were stained for acid-fast bacilli; each sample was cultured singly for M tuberculosis. Median age of children was 13 months (IQR 6-24). A positive smear or culture for M tuberculosis was obtained from 62 (25%) children; of these, 58 (94%) were positive by culture, whereas almost half (29 [47%]) were smear positive. Samples from induced sputum and gastric lavage were positive in 54 (87%) and 40 (65%) children, respectively (difference in yield 5.6% [1.4-9.8%], p=0.018). The yield from one sample from induced sputum was similar to that from three gastric lavages (p=1.0). Microbiological yield did not differ between HIV-infected and HIV-uninfected children (p=0.17, odds ratio 0.7 [95% CI 0.3-1.3]). All sputum induction procedures were well tolerated; minor side-effects were increased coughing, epistaxis, vomiting, or wheezing. Sputum induction is safe and useful for microbiological confirmation of tuberculosis in young children. This technique is preferable to gastric lavage for diagnosis of pulmonary tuberculosis in both HIV-infected and HIV-uninfected infants and children.
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                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Writing – original draft
                Role: ConceptualizationRole: Data curationRole: MethodologyRole: SupervisionRole: Writing – review & editing
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                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: Writing – review & editing
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                Role: Data curationRole: InvestigationRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                plos
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                11 July 2018
                July 2018
                : 15
                : 7
                : e1002591
                Affiliations
                [1 ] Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
                [2 ] Military HIV Research Program, Bethesda, Maryland, United States of America
                [3 ] Montreal Chest Institute, McGill University, Montreal, Quebec, Canada
                [4 ] Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
                [5 ] Centre for International Child Health, Imperial College, London, United Kingdom
                [6 ] Imperial College Healthcare NHS Trust, Institute of Clinical Trials and Methodology, London, United Kingdom
                [7 ] Manson Unit, Médecins Sans Frontières (MSF), London, United Kingdom
                [8 ] The Indus Hospital, Karachi, Pakistan
                [9 ] California Department of Public Health, Sacramento, California, United States of America
                [10 ] Partners In Health, Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts, United States of America
                [11 ] Denver Veterans Affairs Medical Center, National Jewish Health, Denver, Colorado, United States of America
                [12 ] Division of Chronic Infectious Disease, Centers for Disease Control, Taipei, Taiwan
                [13 ] Epidemiological Surveillance Department, Romanian National TB Program, Bucharest, Romania
                [14 ] New York City Department of Health and Mental Hygiene, New York, New York, United States of America
                [15 ] Wits Reproductive Health & HIV Institute (WRHI), University of the Witwatersrand, Johannesburg, South Africa
                [16 ] Laboratories, Diagnostics and Drug Resistance Unit, Global TB Programme, World Health Organization, Geneva, Switzerland
                [17 ] Technical Support Coordination, Global TB Programme, World Health Organization, Geneva, Switzerland
                [18 ] Albert Einstein College of Medicine, Bronx, New York, United States of America
                [19 ] Médecins Sans Frontières (MSF)/Doctors Without Borders, Mumbai, India
                [20 ] Disease Control, Directorate of Health Services, Kashmir, India
                [21 ] Paediatric Infection & Immunity, Centre of International Child Health, Imperial College London, London, United Kingdom
                [22 ] Vaccines & Immunity Theme, MRC Unit The Gambia, Banjul, The Gambia
                [23 ] Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, and Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
                [24 ] Department of Clinical Microbiology and Infectious Diseases, University of the Witwatersrand and the National Health Laboratory Services, Johannesburg, South Africa
                [25 ] Northern State Medical University, Arkhangelsk, Russian Federation
                [26 ] Pediatric, Infectious and Tropical Diseases Department, Hospital La Paz, Madrid, Spain
                [27 ] Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
                [28 ] Republican Scientific Medical Center of Phtiziology and Pulmonology, Ministry of Health, Tashkent, Uzbekistan
                [29 ] Riga Eastern Clinical University Hospital, Centre for Tuberculosis and Lung Diseases, Riga, Latvia
                [30 ] CAPRISA, MRC TB-HIV Pathogenesis Unit, Durban, South Africa
                [31 ] Director Health Services, Kashmir, India
                [32 ] Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
                [33 ] Pediatric Infectious Diseases Unit, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
                [34 ] Department of Pediatrics, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
                [35 ] Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
                [36 ] The Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
                [37 ] Pediatric Infectious Diseases and Immunodeficiencies Unit, Unit of International Health-Tuberculosis Drassanes-Vall Hebron, Hospital Universitari Vall d'Hebron, Barcelona, Spain
                [38 ] Joint Tuberculosis, HIV & Viral Hepatitis Programme, WHO Regional Office for Europe, Copenhagen, Denmark
                [39 ] Disease Programme Tuberculosis, European Centre for Disease Prevention and Control, Stockholm, Sweden
                [40 ] University Medical Center Groningen, Groningen, the Netherlands
                [41 ] Northwick Park Hospital, London Northwest Healthcare NHS Trust, London, United Kingdom
                [42 ] Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
                [43 ] Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
                University of California, San Francisco, UNITED STATES
                Author notes

                I have read the journal's policy and the authors of this manuscript have the following competing interests: DF, MG, and MvDB are staff members of the World Health Organization (WHO). AJGP's institution, Stellenbosch University, has received funds from the US National Institutes of Health for an observational study of the pharmacokinetics and safety of key second-line TB medications in children, for which AJGP is the Principal Investigator. AJGP's institution has also received funds from Otsuka Pharmaceuticals for implementation of pediatric trial of the novel TB drug delamanid; AJGP is the PI for his site for this trial.

                [¤a]

                Current address: Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, United States of America

                [¤b]

                Current address: Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

                ¶ Membership of the Collaborative Group for Meta-Analysis of Paediatric Individual Patient Data in MDR-TB is provided in the Acknowledgments.

                Author information
                http://orcid.org/0000-0001-8117-0607
                http://orcid.org/0000-0002-2296-2302
                http://orcid.org/0000-0001-7424-1868
                http://orcid.org/0000-0003-3903-3320
                http://orcid.org/0000-0001-5190-6767
                http://orcid.org/0000-0001-8798-7909
                http://orcid.org/0000-0001-8861-1225
                http://orcid.org/0000-0002-7881-1554
                http://orcid.org/0000-0002-7855-1043
                http://orcid.org/0000-0002-8485-5625
                http://orcid.org/0000-0003-2543-9071
                http://orcid.org/0000-0001-9613-7228
                http://orcid.org/0000-0002-6417-6668
                http://orcid.org/0000-0001-8021-1358
                http://orcid.org/0000-0002-0825-7199
                Article
                PMEDICINE-D-17-00947
                10.1371/journal.pmed.1002591
                6040687
                29995958
                22d79b3a-90ff-4a42-be08-26abb971abf8

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                History
                : 19 March 2017
                : 18 May 2018
                Page count
                Figures: 4, Tables: 6, Pages: 26
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100004423, World Health Organization;
                Award Recipient :
                Funding for this study was provided through a USAID grant made available by the World Health Organization. DF, MG, and MvdB are WHO employees but not involved in decisions to allocate funding. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Infectious Diseases
                Bacterial Diseases
                Tuberculosis
                Multi-Drug-Resistant Tuberculosis
                Medicine and Health Sciences
                Tropical Diseases
                Tuberculosis
                Multi-Drug-Resistant Tuberculosis
                Medicine and health sciences
                Infectious diseases
                Viral diseases
                HIV infections
                Medicine and Health Sciences
                Infectious Diseases
                Bacterial Diseases
                Tuberculosis
                Medicine and Health Sciences
                Tropical Diseases
                Tuberculosis
                Medicine and Health Sciences
                Pharmaceutics
                Drug Therapy
                Biology and Life Sciences
                Immunology
                Vaccination and Immunization
                Antiviral Therapy
                Antiretroviral Therapy
                Medicine and Health Sciences
                Immunology
                Vaccination and Immunization
                Antiviral Therapy
                Antiretroviral Therapy
                Medicine and Health Sciences
                Public and Occupational Health
                Preventive Medicine
                Vaccination and Immunization
                Antiviral Therapy
                Antiretroviral Therapy
                Medicine and health sciences
                Diagnostic medicine
                HIV diagnosis and management
                People and Places
                Population Groupings
                Age Groups
                Children
                People and Places
                Population Groupings
                Families
                Children
                Medicine and Health Sciences
                Diagnostic Medicine
                Tuberculosis Diagnosis and Management
                Custom metadata
                All data is either available within the paper and its Supporting information files or by contacting the primary points of contact for the original data (see S3 Table).

                Medicine
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