Team approach to manage difficult-to-treat TB cases: Experiences in Europe and beyond.

As recommended by the World Health Organization (WHO), optimal management of MDR-TB cases can be ensured by a multi-speciality consultation body known as 'TB Consilium'. This body usually includes different medical specialities, competences and perspectives (e.g., clinical expertise both for adults and children; surgical, radiological and public health expertise; psychological background and nursing experience, among others), thus lowering the risk of making mistakes - or managing the patients inappropriately, in order to improve their clinical outcomes. At present, several high MDR-TB burden countries in the different WHO regions (and beyond) have introduced TB Consilium-like bodies at the national or subnational level to reach consensus on the best treatment approach for their patients affected by TB. In addition, in countries/settings where a formal system of consultation does not exist, specialized staff from MDR-TB reference centres or international organizations usually spend a considerable amount of their working time responding to phone or e-mail clinical queries on how to manage M/XDR-TB cases. The aim of this manuscript is to describe the different experiences with the TB Consilia both at the international level (European Respiratory Society - ERS/WHO TB Consilium) and in some of the countries where this experience operates successfully in Europe and beyond. The Consilium experiences are described around the following topics: (1) history, aims and focus; (2) management and funding; (3) technical functioning and structure; (4) results achieved. In addition a comparative analysis of the TB Consilia in the different countries has been performed.

Update on the diagnosis and treatment of pulmonary tuberculosis.

Tuberculosis (TB) remains the most important human infectious disease. Currently, the TB diagnosis is still based on the clinical presentation, radiographic findings and microbiological results; all of which have sensitivity or specificity issues. For that reason, the immediate future involves rapid molecular microbiological techniques, in particular GeneXpert (which is more sensitive than bacilloscopy and is able to detect rifampicin resistance) and GenoType. The current six-month treatment for TB has remained unchanged for decades. Attempts to shorten this treatment have failed. In recent years, new drugs have been reported that could contribute to TB treatment in the near future, and are already being used in multi-drug-resistance TB.

[Complications of endovesical treatment with BCG in a series of 200 patients]. / Complicaciones del tratamiento endovesical con BCG en una serie de doscientos pacientes.

OBJECTIVE: To describe and quantify the side effects of intravesical BCG therapy (Connaught strain) in different therapeutic protocols. METHODS: 200 patients were studied; 126 treated according to the standard protocol of our hospital (modality 1 and modality 2: twelve and nine 81 mg instillations, respectively) and 74 patients in the CUETO protocols (90008, 93009, 95011, 95012). Classification of BCG toxicity was based on the criteria utilized by Lamm which divides it into side effects and complications. We have distinguished side effects further as local irritative symptoms (LIS) and cystitis. RESULTS: The most common side effects were LIS (80%) and cystitis (21.5%). The incidence of cystitis (44.4%) and general malaise (44.4%) was higher for modality 1 than for modality 2 (24.1% and 20.3%, respectively). The CUETO 93009 protocol (mitomycin + BCG) showed the highest incidence of side effects (LIS 100%, cystitis 57.1% and fever < 39 degrees C 71.4%). The most frequent complication was fever > 39 degrees C (4%), followed by hepatitis (3%). The rate of bladder retraction was notably high (1.5%), requiring cystectomy with neobladder substitution in two cases. The overall complication rate for modality 1 (16.6%) was reduced when modality 2 was utilized (8.3%). In the CUETO 90008 protocol, dose reduction did not reduce the complication rate (81 mg: 7.1%; 21 mg: 19.2%). BCG therapy was discontinued in 14%. CONCLUSIONS: Toxicity due to intravesical BCG therapy did not decrease when the dose was reduced, but diminished in number and intensity when the number of consecutive instillations was reduced.

[The efficacy of bronchoalveolar lavage in the diagnosis of pulmonary tuberculosis]. / Rentabilidad del lavado broncoalveolar en el diagnóstico de la tuberculosis pulmonar.

In order to analyze the usefulness of bronchoalveolar lavage (BAL) for conventional microbiological diagnosis of tuberculosis (TB) and other mycobacteria, and to assess the need to use it or not as a routine diagnostic technique in these diseases, we studied 30 patients with mycobacteria (26 TB and 4 Mycobacterium avium-intracellulare infections) by bronchoscopy, with BAL and bronchoaspirate (BAS) bacteriological analyses also available. The results were compared with those obtained for sputum taken before and after bronchoscopy when these specimens were available. The overall yield for BAL and BAS cultures was 90%, with BAL (83.3%) specimens being more productive than BAS (73.3%) specimens. Both performed far better than the 53.8% recorded for cultures of pre-bronchoscopy sputum and 60% for post-bronchoscopy sputum. BAL was the only diagnostic specimen from 7 patients, while BAS the only one from 4. Sensitivity was similar for the two mycobacteria studied. The results for direct bacilloscopy, however, at 30% for the two specimens, rose to 36.6% when they were analyzed together with BAS and BAL. We conclude that bronchoscopy should be performed on all patients suspected of mycobacterial infection when sputum bacilloscopy is negative and patients have no expectoration. Performance of BAL should be routine since this simple and usually uncomplicated technique produces the most productive specimens.

[The usefulness of elastin fibers as a diagnostic marker in ventilator-related pneumonia]. / Utilidad de las fibras de elastina como marcador diagnóstico de la neumonía asociada al ventilador.

The diagnosis of nosocomial pneumonia is especially difficult in intubated patients due to the low specificity of their clinico-radiological signs. The objective of this study was to evaluate the usefulness of basing diagnosis on elastin fibers (EF) in bronchoaspirate (BAS) as an indication of pneumonia in mechanically-ventilated (MV) patients. Forty-seven MV patients suspected of having nosocomial pneumonia were studied prospectively. Fiber bronchoscopy was carried out on all patients and samples were obtained using a protected catheter brush (PCB) and bronchoalveolar lavage (BAL). A purulent sample of BAS was also examined, after addition of 40% KOH, to determine the presence of EF. EF was found in 15 patients, 11 of whom had pneumonia while 3 more had necrotizing pneumonia (sensitivity 52%, specificity 85%). Ten of the 17 microorganisms isolated in the cases of EF positive pneumonia were gram negative, although the germ found most often was S. aureus. There were no differences in the prognosis for pneumonia patients who were EF positive and those who were EF negative. In conclusion, once necrotizing pneumopathology has been ruled out, the presence of EF in BAS may offer reasonable support for firm diagnosis in some MV patients with pneumonia.