Treatment correlates of successful outcomes in pulmonary multidrug-resistant tuberculosis: an individual patient data meta-analysis
de Vries, G
van der Werf, TS
MetadataShow full item record
AbstractBACKGROUND: Treatment outcomes for multidrug-resistant tuberculosis remain poor. We aimed to estimate the association of treatment success and death with the use of individual drugs, and the optimal number and duration of treatment with those drugs in patients with multidrug-resistant tuberculosis. METHODS: In this individual patient data meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library to identify potentially eligible observational and experimental studies published between Jan 1, 2009, and April 30, 2016. We also searched reference lists from all systematic reviews of treatment of multidrug-resistant tuberculosis published since 2009. To be eligible, studies had to report original results, with end of treatment outcomes (treatment completion [success], failure, or relapse) in cohorts of at least 25 adults (aged >18 years). We used anonymised individual patient data from eligible studies, provided by study investigators, regarding clinical characteristics, treatment, and outcomes. Using propensity score-matched generalised mixed effects logistic, or linear regression, we calculated adjusted odds ratios and adjusted risk differences for success or death during treatment, for specific drugs currently used to treat multidrug-resistant tuberculosis, as well as the number of drugs used and treatment duration. FINDINGS: Of 12 030 patients from 25 countries in 50 studies, 7346 (61%) had treatment success, 1017 (8%) had failure or relapse, and 1729 (14%) died. Compared with failure or relapse, treatment success was positively associated with the use of linezolid (adjusted risk difference 0·15, 95% CI 0·11 to 0·18), levofloxacin (0·15, 0·13 to 0·18), carbapenems (0·14, 0·06 to 0·21), moxifloxacin (0·11, 0·08 to 0·14), bedaquiline (0·10, 0·05 to 0·14), and clofazimine (0·06, 0·01 to 0·10). There was a significant association between reduced mortality and use of linezolid (-0·20, -0·23 to -0·16), levofloxacin (-0·06, -0·09 to -0·04), moxifloxacin (-0·07, -0·10 to -0·04), or bedaquiline (-0·14, -0·19 to -0·10). Compared with regimens without any injectable drug, amikacin provided modest benefits, but kanamycin and capreomycin were associated with worse outcomes. The remaining drugs were associated with slight or no improvements in outcomes. Treatment outcomes were significantly worse for most drugs if they were used despite in-vitro resistance. The optimal number of effective drugs seemed to be five in the initial phase, and four in the continuation phase. In these adjusted analyses, heterogeneity, based on a simulated I2 method, was high for approximately half the estimates for specific drugs, although relatively low for number of drugs and durations analyses. INTERPRETATION: Although inferences are limited by the observational nature of these data, treatment outcomes were significantly better with use of linezolid, later generation fluoroquinolones, bedaquiline, clofazimine, and carbapenems for treatment of multidrug-resistant tuberculosis. These findings emphasise the need for trials to ascertain the optimal combination and duration of these drugs for treatment of this condition.
- Comparison of different treatments for isoniazid-resistant tuberculosis: an individual patient data meta-analysis.
- Authors: Fregonese F, Ahuja SD, Akkerman OW, Arakaki-Sanchez D, Ayakaka I, Baghaei P, Bang D, Bastos M, Benedetti A, Bonnet M, Cattamanchi A, Cegielski P, Chien JY, Cox H, Dedicoat M, Erkens C, Escalante P, Falzon D, Garcia-Prats AJ, Gegia M, Gillespie SH, Glynn JR, Goldberg S, Griffith D, Jacobson KR, Johnston JC, Jones-López EC, Khan A, Koh WJ, Kritski A, Lan ZY, Lee JH, Li PZ, Maciel EL, Galliez RM, Merle CSC, Munang M, Narendran G, Nguyen VN, Nunn A, Ohkado A, Park JS, Phillips PPJ, Ponnuraja C, Reves R, Romanowski K, Seung K, Schaaf HS, Skrahina A, Soolingen DV, Tabarsi P, Trajman A, Trieu L, Banurekha VV, Viiklepp P, Wang JY, Yoshiyama T, Menzies D
- Issue date: 2018 Apr
- Linezolid for drug-resistant pulmonary tuberculosis.
- Authors: Singh B, Cocker D, Ryan H, Sloan DJ
- Issue date: 2019 Mar 20
- Cost-effectiveness of adding novel or group 5 interventions to a background regimen for the treatment of multidrug-resistant tuberculosis in Germany.
- Authors: Wirth D, Dass R, Hettle R
- Issue date: 2017 Mar 8
- Effectiveness and safety of bedaquiline-containing regimens in the treatment of MDR- and XDR-TB: a multicentre study.
- Authors: Borisov SE, Dheda K, Enwerem M, Romero Leyet R, D'Ambrosio L, Centis R, Sotgiu G, Tiberi S, Alffenaar JW, Maryandyshev A, Belilovski E, Ganatra S, Skrahina A, Akkerman O, Aleksa A, Amale R, Artsukevich J, Bruchfeld J, Caminero JA, Carpena Martinez I, Codecasa L, Dalcolmo M, Denholm J, Douglas P, Duarte R, Esmail A, Fadul M, Filippov A, Davies Forsman L, Gaga M, Garcia-Fuertes JA, García-García JM, Gualano G, Jonsson J, Kunst H, Lau JS, Lazaro Mastrapa B, Teran Troya JL, Manga S, Manika K, González Montaner P, Mullerpattan J, Oelofse S, Ortelli M, Palmero DJ, Palmieri F, Papalia A, Papavasileiou A, Payen MC, Pontali E, Robalo Cordeiro C, Saderi L, Sadutshang TD, Sanukevich T, Solodovnikova V, Spanevello A, Topgyal S, Toscanini F, Tramontana AR, Udwadia ZF, Viggiani P, White V, Zumla A, Migliori GB
- Issue date: 2017 May
- Provisional CDC guidelines for the use and safety monitoring of bedaquiline fumarate (Sirturo) for the treatment of multidrug-resistant tuberculosis.
- Authors: Centers for Disease Control and Prevention.
- Issue date: 2013 Oct 25