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

Date Published: July 11, 2018

Publisher: Public Library of Science

Author(s): Elizabeth P. Harausz, Anthony J. Garcia-Prats, Stephanie Law, H. Simon Schaaf, Tamara Kredo, James A. Seddon, Dick Menzies, Anna Turkova, Jay Achar, Farhana Amanullah, Pennan Barry, Mercedes Becerra, Edward D. Chan, Pei Chun Chan, Domnica Ioana Chiotan, Aldo Crossa, Peter C. Drobac, Lee Fairlie, Dennis Falzon, Jennifer Flood, Medea Gegia, Robert M. Hicks, Petros Isaakidis, SM Kadri, Beate Kampmann, Shabir A. Madhi, Else Marais, Andrei Mariandyshev, Ana Méndez-Echevarría, Brittany Kathryn Moore, Parpieva Nargiza, Iveta Ozere, Nesri Padayatchi, Saleem- ur-Rehman, Natasha Rybak, Begoña Santiago-Garcia, N. Sarita Shah, Sangeeta Sharma, Tae Sun Shim, Alena Skrahina, Antoni Soriano-Arandes, Martin van den Boom, Marieke J. van der Werf, Tjip S. van der Werf, Bhanu Williams, Elena Yablokova, Jae-Joon Yim, Jennifer Furin, Anneke C. Hesseling, John Z. Metcalfe

Abstract: BackgroundAn 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 findingsTo 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 To identify unpublished data, we reviewed conference abstracts, contacted experts in the field, and requested data through other routes, including at national and international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 All data were from published or unpublished observational cohorts.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.ConclusionsThis 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.

Partial Text: Almost 500,000 people developed multidrug-resistant tuberculosis (MDR-TB) (defined as Mycobacterium tuberculosis with resistance to at least isoniazid and rifampin) in 2015 [1]. Despite the fact that as many as 32,000 children younger than 15 years of age develop MDR-TB globally each year, little is known about the optimal treatment for children with MDR-TB [2]. The diagnosis and treatment of MDR-TB in children is challenging: it can be difficult to bacteriologically confirm the diagnosis because of difficulties in collecting respiratory samples in younger children and in children who frequently have paucibacillary (smear- or culture-negative) disease [3].

This systematic review and IPD meta-analysis of pediatric MDR-TB represents a global collaborative effort of the pediatric TB community. It has for the first time, to our knowledge, generated a data set of children treated for MDR-TB in multiple countries, which has informed the revised 2016 WHO MDR-TB treatment guidelines [4].

Source:

http://doi.org/10.1371/journal.pmed.1002591

 

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