Pneumococcal disease burden from an Indian perspective: Need for its prevention in pulmonology practice.

Globally, pneumococcal diseases are a significant public health concern. They are preventable and frequently occur among older adults. Major risk factors for the disease are extremes of age, alcohol intake, smoking, air pollution, and comorbid conditions (diabetes, chronic obstructive pulmonary disease, chronic kidney disease, liver disease, and heart disease). Risk factors, coupled with limited disease-burden data and the emergence of antibiotics resistance, are hindering the effective management of the disease in older adults. Various global guidelines recommend pneumococcal vaccines for the prevention of pneumococcal diseases, as they reduce disease burden, hospitalization, and mortality rates among patients with comorbid conditions. Besides being an integral part of childhood immunization, these vaccines are advocated by various Indian healthcare bodies/groups for older and younger adults with certain medical conditions. The article presents an overview of the closed-door discussion by the Indian pulmonary experts on the scientific evidence and clinical practice followed for the prevention of pneumococcal disease in India.

Six versus 12 Months of Anti Tubercular Therapy in Patients With Biopsy Proven Spinal Tuberculosis: A Single Center, Open Labeled, Prospective Randomized Clinical Trial-A Pilot study.

STUDY DESIGN: A single center pilot study, open labeled, prospective randomized clinical trial. OBJECTIVE: To compare six versus 12 months of anti TB therapy in patients with biopsy proven spinal TB. SUMMARY OF BACKGROUND DATA: There is no clear consensus or evidence based guidelines for the duration of treatment of spinal tuberculosis. We studied if 6 and 12 months of anti tubercular therapy (ATT) had equivalent outcomes at 24 months from completion of therapy. METHODS: A prospective randomized open labeled clinical trial of 6 versus 12 months ATT in patients with biopsy proven spinal-vertebral tuberculosis. The primary end point was absence of recurrence 24 months after completing therapy. Secondary end points were clinical cure at the end of therapy, significant adverse effect of ATT, need for delayed surgery, and residual neurological dysfunction. RESULTS: Hundred patients, randomized to 6 or 12 months ATT, were followed up for a minimum of 24 months from completion of therapy. All patients completed scheduled duration of ATT, with one crossover from 6 months ATT group to 12 months. There were no recurrences of disease on the 24 months follow up following completion of ATT. All 100 patients met criteria for cure at time of stopping medicines. One patient (12 months group) had residual neurological dysfunction at the time of stopping treatment, which completely resolved over the next 12 months.There were no patients with major drug induced hepatitis. One patient (12 months group) needed percutaneous drainage of an abscess. None needed surgical re-exploration for persistent infection of implant removal. CONCLUSION: This pilot study concludes that, in patients with biopsy proven spinal-vertebral, TB, 6 and 12 months of ATT give similar clinical outcomes at 24 months of completion of therapy. LEVEL OF EVIDENCE: 2.

Drug resistance patterns in 111 cases of drug-resistant tuberculosis spine.

PURPOSE: We report the largest study conducted till date of drug resistant tuberculosis in spine analyzing the drug susceptibility patterns in 111 cases of proven drug resistance. METHODS: An observed cross-sectional study was conducted. Six-hundred and eighty-six patients with positive cultures underwent sensitivity testing to 13 commonly used anti-tubercular drugs using BACTEC MGIT-960 system. RESULTS: Females (60.3%) outnumbered males (39.6%). Only three patients (2.7%) were found HIV positive, and none of these had AIDS. Forty-four (39.6%) patients had taken AKT in the past for some form of tuberculosis. Eight (7.2%) patients had history of treatment default. The drug sensitivity testing revealed 87 (78.3%) cases of multi drug resistance (resistance to both isoniazid and rifampicin) and 3 (2.7%) cases of XDR-TB spine. Of the individual drugs, widespread resistance was present to both isoniazid (92.7%) and rifampicin (81.9%), followed by streptomycin (69.3%). Least resistance was found to kanamycin, amikacin and capreomycin. CONCLUSION: It is recommended to do routine biopsy, culture and drug sensitivity testing in all patients of tuberculosis spine to guide selection of appropriate second-line drugs when required. In cases of non availability of drug susceptibility testing despite repeated attempts, it is suggested to use data from large series such as this to plan best empirical chemotherapy protocol.

Multidrug-resistant tuberculosis of the spine--is it the beginning of the end? A study of twenty-five culture proven multidrug-resistant tuberculosis spine patients.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: We report the first study of multidrug-resistant tuberculosis (MDR-TB) in the spine. The aim was to determine the clinical, radiologic, and drug resistance profile as well as the factors associated with treatment outcome of MDR-TB in the spine. SUMMARY OF BACKGROUND DATA: Tuberculosis of the spine is the most common extrapulmonary form of tuberculosis in the Asian subcontinent. The disease in few cases is resistant to the primary anti-Koch's medications and the number of cases detected is on the rise. Multidrug resistant form of tuberculosis of the spine is ill reported in the literature. The diagnosis, management thus remains a challenge to the treating surgeon. This study tries to assess these critical issues of this "new" disease. METHODS: Described here are the clinical characteristics of 25 MDR-TB spine patients identified in the study and their drug susceptibility patterns. They were followed up clinically, radiologically after a biopsy, culture, and Drug Susceptibility Testing. According to their Drug Susceptibility Testing pattern and previous history of Anti-Tubercular Treatment (ATT), individualized treatment regimens were tailored for each patient by an expert physician. RESULTS: Majority of the patients seen in the present study were in the productive years of their life. (Males (9) mean age: 38.5 years and females (16) mean age: 34.3 years. Four patients were defaulters of the ATT. The average number of drugs used was 6, including 4 second line drugs. Average treatment duration was 24 months. Almost 50% of the patients had adverse drug effects. Of the 25 patients, 19 achieved healed status and 6 are still on treatment. Four patients required surgery for mechanical instability of the spine. Radiologic improvement was observed in all the cases after a mean treatment of 6 months. Five predictors were identified for successful outcome of MDR-TB. They include progressive clinical improvement at 6 months, radiologic improvement during treatment and disease with Mycobacterium tuberculosis strains exhibiting resistance to less than or up to 3 antitubercular drugs, use of less than or up to 4 second-line drugs in treatment, and no change of regimen during treatment. CONCLUSION: MDR-TB of the spine is a different disease and is here to stay. There is an urgent need to include culture and drug susceptibility testing in the protocol for the treatment of tuberculosis of the spine.