RESUMEN
OBJECTIVES: Antimicrobial resistance (AMR) is a priority for surveillance in bacterial infections. For leprosy, AMR has not been assessed because Mycobacterium leprae does not grow in vitro. We aim to obtain AMR data using molecular detection of resistance genes and to conduct a prospective open survey of resistance to antileprosy drugs in countries where leprosy is endemic through a WHO surveillance network. METHODS: From 2009 to 2015, multi-bacillary leprosy cases at sentinel sites of 19 countries were studied for resistance to rifampicin, dapsone and ofloxacin by PCR sequencing of the drug-resistance-determining regions of the genes rpoB, folP1 and gyrA. RESULTS: Among 1932 (1143 relapse and 789 new) cases studied, 154 (8.0%) M. leprae strains were found with mutations conferring resistance showing 182 resistance traits (74 for rifampicin, 87 for dapsone and 21 for ofloxacin). Twenty cases showed rifampicin and dapsone resistance, four showed ofloxacin and dapsone resistance, but no cases were resistant to rifampicin and ofloxacin. Rifampicin resistance was observed among relapse (58/1143, 5.1%) and new (16/789, 2.0%) cases in 12 countries. India, Brazil and Colombia reported more than five rifampicin-resistant cases. CONCLUSIONS: This is the first study reporting global data on AMR in leprosy. Rifampicin resistance emerged, stressing the need for expansion of surveillance. This is also a call for vigilance on the global use of antimicrobial agents, because ofloxacin resistance probably developed in relation to the general intake of antibiotics for other infections as it is not part of the multidrug combination used to treat leprosy.
Asunto(s)
Antibacterianos/uso terapéutico , Farmacorresistencia Bacteriana/genética , Lepra/epidemiología , Mycobacterium leprae/efectos de los fármacos , Mycobacterium leprae/genética , Antibacterianos/efectos adversos , Proteínas Bacterianas/genética , Biopsia con Aguja , Brasil/epidemiología , Colombia/epidemiología , Girasa de ADN/genética , Dapsona/uso terapéutico , Enfermedades Endémicas/estadística & datos numéricos , Monitoreo Epidemiológico , Salud Global , Humanos , India/epidemiología , Lepra/diagnóstico , Lepra/tratamiento farmacológico , Lepra/microbiología , Pruebas de Sensibilidad Microbiana , Mutación , Ofloxacino/uso terapéutico , Reacción en Cadena de la Polimerasa , Estudios Prospectivos , Recurrencia , Rifampin/uso terapéutico , Vigilancia de Guardia , Piel/microbiología , Piel/patología , Encuestas y Cuestionarios , Organización Mundial de la SaludRESUMEN
SETTING: Significance of a positive bacillary examination of sputum at 2 months of treatment in relation to the viability of the bacilli and the final treatment result. OBJECTIVE: To compare the results of smear microscopy and sputum culture at the second month of tuberculosis treatment and to follow the progress of the patients. METHODS: Follow-up of 297 patients with smear-positive pulmonary tuberculosis in Madagascar, 152 of whom were smear-positive at 2 months of treatment and 145 smear-negative. The number of bacilli was recorded, as were the culture results and the final outcome of treatment. RESULTS: Among the 152 patients who were smear-positive at the second month, 77 (51%) were culture-negative; there were 12 (8%) treatment failures and four relapses (4.6%). Among the 145 smear-negative patients, 22 (15%) were culture-positive, of which one was a treatment failure (1%). CONCLUSION: The majority of failures and relapses were observed in the group of smear-positive patients. It is important to reinforce the surveillance of these patients in order to reduce the number lost to follow-up. Furthermore, a positive smear microscopy at the end of the second month is not sufficiently specific for early identification of treatment failures. It is preferable to wait until the fifth month, as the great majority of patients who are positive at 2 months achieve cure. The treatment strategy currently recommended in Madagascar is satisfactory.
Asunto(s)
Antituberculosos/uso terapéutico , Microscopía , Mycobacterium tuberculosis/aislamiento & purificación , Mycobacterium tuberculosis/ultraestructura , Esputo/microbiología , Tuberculosis Pulmonar/microbiología , Tuberculosis Pulmonar/patología , Recuento de Colonia Microbiana , Estudios de Seguimiento , Humanos , Recurrencia , Factores de Tiempo , Resultado del Tratamiento , Tuberculosis Pulmonar/tratamiento farmacológicoRESUMEN
Tuberculosis during childhood is often due to Mycobacterium tuberculosis primo-infection. Tuberculosis is highly prevalent in Madagascar and most people are infected during childhood. Our objectives were to evaluate the primary resistance of M. tuberculosis and to determine the genotypes responsible for recent infection in the population. Thus we studied 142 isolated strains from 97 children (66 with pulmonary tuberculosis and 31 with extra-pulmonary tuberculosis) recruited in different health centers in Antananarivo from 1997 to 2000. Excepting one strain resistant to isoniazide, all strains were susceptible to the four antibiotics (streptomycin, isoniazid, ryfampicin and ethambutol). This result confirms the low rate of primary resistance reported during the two surveys in 1994-1995 and 1999-2000. 67 strains of 1997-2000 were typed with the genetic marker IS6110, 44 has been assigned to 13 clusters containing each 2 to 8 similar strains. Some IS6110 clusters have already been reported in 1994-1995. Some genotypes observed in 1994-1995 seemed to have disappeared in 1997-2000. (As the rate of the frequency of some genetic variants according to the period are more likely due to a difference in strain virulence). Since there is minimal antibiotic resistance versus M. tuberculosis in Madagascar, one can not explain the appearance or disappearance of certain variants because of drug resistance. Rather, this is due to the virulence of the various M. tuberculosis strains.
Asunto(s)
Mycobacterium tuberculosis/efectos de los fármacos , Mycobacterium tuberculosis/genética , Tuberculosis/epidemiología , Tuberculosis/microbiología , Salud Urbana/estadística & datos numéricos , Distribución por Edad , Antituberculosos/uso terapéutico , Niño , Preescolar , Análisis por Conglomerados , ADN Bacteriano/genética , Farmacorresistencia Bacteriana , Genes Dominantes , Genotipo , Encuestas Epidemiológicas , Humanos , Incidencia , Lactante , Recién Nacido , Madagascar/epidemiología , Pruebas de Sensibilidad Microbiana , Epidemiología Molecular , Mycobacterium tuberculosis/clasificación , Polimorfismo Genético , Polimorfismo de Longitud del Fragmento de Restricción , Vigilancia de la PoblaciónRESUMEN
Since June 1997, a quarterly quality control of sputum smear exam for the tubercle diagnosis, depending on double reading of slides, was implemented between both central laboratories of the Mycobacteria National Reference Centre in Madagascar (mycobactoria laboratories of Institut Pasteur Madagascar [IPM] and Institut Hygiène Sociale [IHS]--Health Ministry). In 2000, four controls were done, in the course of which 240 slides were coloured by auramine, coming both from IPM and IHS, and another 80 slides from IHS were coloured by Ziehl-Neelsen. All the results were in agreement for the samples stained with auramine, while two false negatives were found for the samples stained with Ziehl-Neelsen. The maintenance of this quality control between the two laboratories is necessary to insure the reliability of their results and the controls that they make for the peripheral laboratories.
Asunto(s)
Técnicas Bacteriológicas/normas , Técnicas de Laboratorio Clínico/normas , Garantía de la Calidad de Atención de Salud/organización & administración , Esputo/microbiología , Tuberculosis/diagnóstico , Técnicas Bacteriológicas/métodos , Humanos , Madagascar , Programas Nacionales de Salud/normas , Control de Calidad , Manejo de Especímenes/métodos , Manejo de Especímenes/normas , Tuberculosis/microbiologíaRESUMEN
In 1991, the National Tuberculosis control Program (NTP) of Madagascar adopted the short treatment course and the Directly Observed Treatment Strategy (DOTS), according to the recommendations of the OMS/UICTMR. Development of M. tuberculosis primary resistance to the four antituberculosis drugs (streptomycin [S], rifampicine [R], isoniazid [H], ethambutol [E]) is an indicator of the NTP efficiency. We report results from a five-year survey among patients with new smear positive pulmonary tuberculosis. Acquired resistance is assessed among recurrent cases. During the first survey, carried out in 1994-1995 in four large cities, multidrug resistance (MDR) rate to the major antituberculosis drug H and R was low, 0.25% for primary MDR and 5% for acquired MDR. No primary MDR was found in Antananarivo; on the other hand, acquired resistance rate was the highest there (22%). Because of logistical reasons, the second survey (1999-2000) was only carried out in the capital, Antananarivo. Results obtained among 789 new patients with smear positive pulmonary tuberculosis and 79 recurrents cases in 9 diagnostic centres showed low primary and acquired resistance of 11.1% to any drug. Primary resistance to one drug was 10.6%, mainly due to streptomycin 8.5%. MDR rates are comparable with those observed in 1994-1995: 0.1% for primary MDR and 4% for acquired MDR. These results show that ten years after the new NTP implementation, only a few MDR strains are circulating in Antananarivo, which suggests that NTP has been effective.
Asunto(s)
Antituberculosos/uso terapéutico , Farmacorresistencia Bacteriana Múltiple/genética , Mycobacterium tuberculosis/efectos de los fármacos , Mycobacterium tuberculosis/genética , Tuberculosis Resistente a Múltiples Medicamentos/epidemiología , Tuberculosis Resistente a Múltiples Medicamentos/microbiología , Tuberculosis Pulmonar/epidemiología , Tuberculosis Pulmonar/microbiología , Salud Urbana/estadística & datos numéricos , Antibióticos Antituberculosos/uso terapéutico , Terapia por Observación Directa , Etambutol/uso terapéutico , Femenino , Humanos , Isoniazida/uso terapéutico , Madagascar/epidemiología , Masculino , Pruebas de Sensibilidad Microbiana , Epidemiología Molecular , Programas Nacionales de Salud , Vigilancia de la Población , Estudios Prospectivos , Recurrencia , Rifampin/uso terapéutico , Estreptomicina/uso terapéutico , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Tuberculosis Pulmonar/tratamiento farmacológicoRESUMEN
As part of the National Tuberculosis Program (NTP), a quality control of the slides (search of acido-fast bacilli in the sputa) of the Treatment and Diagnosis Centers (TDC) forming the National Laboratory Network is carried out each year. In 1999, 76 TDC out of the 174 (44%) had been controlled using the method of double reading of the smears. The global concordance of the results in the 76 TDC is satisfactory (98%). Reability was 91% for the positive smears and 92% for the negative smears. A good quality of smears was observed in 53% of the centers. The TDC reliable at 100% for both positive and negative smears were 51 (67%) of which 36 (47%) had also a good quality of smears. Those later were mainly found in Toamasina, Fianarantsoa, Antananarivo and Mahajanga.
Asunto(s)
Técnicas Bacteriológicas/normas , Laboratorios/normas , Manejo de Especímenes/normas , Esputo/microbiología , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/microbiología , Método Doble Ciego , Reacciones Falso Negativas , Reacciones Falso Positivas , Humanos , Madagascar , Control de CalidadRESUMEN
SETTING: Seven tuberculosis clinics in the National Tuberculosis Programme of Madagascar. OBJECTIVE: To compare the treatment efficacy and tolerance of regimens including either streptomycin or ethambutol for patient compliance during initial treatment of smear-positive tuberculosis. DESIGN: The 1023 patients included in the study were randomly divided into two treatment groups-one to receive streptomycin (S), isoniazid (H), rifampicin (R) and pyrazinamide (Z) (SHRZ), and the other to receive EHRZ, where streptomycin was replaced by ethambutol (E). During the 2-month intensive phase, drug delivery was completely supervised. The same 6-month continuation regimen was then given in both groups. Follow-up consisted of a clinical and bacteriological examination at the end of the second, fifth and eighth months. RESULTS: There was no significant difference between the two regimens as regards compliance with treatment, the number of patients lost or who died, or for bacteriological response during the intensive phase. EHRZ was better tolerated. During the continuation phase, the results of the two groups remained comparable, but treatment failures occurred earlier in the patients who had received streptomycin. CONCLUSION: Patient compliance was not better with streptomycin. The ethambutol-containing regimen was as efficient as the other, and better tolerated. There is no argument for preferring streptomycin in the intensive phase of treatment of smear-positive tuberculosis.
Asunto(s)
Antibióticos Antituberculosos/uso terapéutico , Antituberculosos/uso terapéutico , Etambutol/uso terapéutico , Cooperación del Paciente , Estreptomicina/uso terapéutico , Tuberculosis Pulmonar/tratamiento farmacológico , Adolescente , Adulto , Anciano , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
A national anti-tuberculosis program has been in operation in Madagascar since 1991. Despite the significant efforts made in the management, education and surveillance of patients, the number of patients lost to treatment remains high (18.8%). Noncompliance with treatment is the principal cause of treatment failure and of the development of resistance to tuberculosis drugs. This study investigated the profile of the patients who discontinue treatment. The study population consisted of the patients withdrawing from a clinical trial carried out between August 1994 and September 1996. The aim of the trial was to compare several treatments in routine practice conditions in Madagascar. The treatments tested were streptomycin (S) or ethambutol (E) associated with isoniazid (H), rifampicin (R) or pyrazinamide (Z) for the first two months, followed by 6 months of treatment H and thiacetazone (T). The trial involved four public and three private diagnosis and treatment centers in Antananarivo, Fianarantsoa and Mahajanga. A total of 1, 023 patients were included in the trial and 192 (18.8%) withdrew during the eight-month treatment period. We tracked down 109 of these patients (56.8%) and 19 patients came back to the treatment center on their own initiative for a checkup. The rate of response to a recall letter sent by mail was low. The 106 patients interviewed mostly gave professional, financial or family reasons for discontinuing treatment. Many patients stopped the treatment as soon as they began to feel better. To reduce the number of patients discontinuing treatment, the National Anti-Tuberculosis Program should improve the education of patients and their families.
Asunto(s)
Antituberculosos/administración & dosificación , Pacientes Desistentes del Tratamiento , Tuberculosis/tratamiento farmacológico , Adolescente , Adulto , Anciano , Antibióticos Antituberculosos/administración & dosificación , Quimioterapia Combinada , Etambutol/administración & dosificación , Femenino , Humanos , Isoniazida/administración & dosificación , Madagascar , Masculino , Persona de Mediana Edad , Pirazinamida/administración & dosificación , Rifampin/administración & dosificación , Estreptomicina/administración & dosificación , Tioacetazona/administración & dosificación , Factores de Tiempo , Tuberculosis/prevención & controlRESUMEN
SETTING: A new tuberculosis control programme has been implemented in Madagascar since 1991. A survey on Mycobacterium tuberculosis resistance to the major drugs was conducted between August 1994 and December 1995. OBJECTIVE: To determine primary and acquired resistance in pulmonary tuberculosis patients in four main cities. DESIGN: Were included 401 randomly sampled new smear positive patients (36.2% of declared new patients) and 137 recurrent cases (72.9% of declared cases) from 8 centres. Drug susceptibility testing was performed on Löwenstein Jensen medium according to the proportion method. RESULTS: The male to female ratio was 1.35:1 in new patients (age range 11-74 years) and 1.98:1 in recurrent patients (age range 16-76 years). The primary resistance rate to any drug was 20% (95% Confidence Interval [CI] 16-23) and the acquired resistance rate 40% (95% CI 32-48, P < 2.10(-7). Primary resistance to one drug was 18% (95% CI 15-22), mainly attributable to streptomycin resistance (14.5%). Multidrug resistance (MDR) to isoniazid and rifampicin was 0.25% (95% CI 0-0.7) for primary resistance and 5% (95% CI 2.6-10.6) for secondary resistance. No difference was observed between sexes or ages. CONCLUSION: This survey conducted in big cities gives a very negative picture of resistance in Madagascar.
Asunto(s)
Antituberculosos/uso terapéutico , Tuberculosis Resistente a Múltiples Medicamentos/epidemiología , Tuberculosis Pulmonar/tratamiento farmacológico , Tuberculosis Pulmonar/epidemiología , Adolescente , Adulto , Distribución por Edad , Anciano , Antituberculosos/farmacología , Niño , Intervalos de Confianza , Recolección de Datos , Femenino , Humanos , Madagascar/epidemiología , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Prevalencia , Distribución Aleatoria , Recurrencia , Distribución por SexoRESUMEN
SETTING: The Regional Tuberculosis Centre and the Muraz Centre in Bobo-Dioulasso, Burkina Faso. OBJECTIVES: To observe the trend of primary drug resistance in pulmonary tuberculosis patients 5 years into a short-course treatment programme and to assess the possible implementation of a further programme. DESIGN: Bacteriological study of stains isolated from all newly diagnosed tuberculosis patients (n = 300), all relapse cases (n = 20) and all failure cases (n = 58) from the Houet province, during the period from April 1992 to April 1994. Human immunodeficiency virus (HIV) serostatus was determined for the first 119 patients included in the study. RESULTS: Mycobacterium tuberculosis was the predominant species as shown by 75.1% of the isolates; next was M. africanum, then atypical mycobacteria and finally M. bovis, representing 18.4%, 6.5% and 0.4% of the isolates respectively. Primary resistance (excluding atypical strains) was as follows: isoniazid 7.6%, ethambutol 1.0%, rifampicin 2.5%, and streptomycin 12.4%; 33.6% of the patients tested for HIV were HIV positive. There was no relationship between HIV serostatus and the identity of strains or drug resistance. However, negative acid-fast bacilli smear microscopy with positive culture was significantly more frequent in HIV-positive patients than in HIV-negative patients. CONCLUSION: This study shows a drop in primary resistance compared with previous studies carried out in Bobo-Dioulasso under the same conditions (setting, materials and methods, sampling procedures) in 1982 and 1986. This is consistent with the hypothesis that treatment monitoring and the introduction of short-course therapy in 1989 (2 HERZ/4 HR or 2 HRSZ/4 HR) have contributed to lower rates of primary drug resistance.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Antituberculosos/farmacología , Mycobacterium tuberculosis/efectos de los fármacos , Tuberculosis Pulmonar/tratamiento farmacológico , Infecciones Oportunistas Relacionadas con el SIDA/microbiología , Adulto , Antituberculosos/uso terapéutico , Burkina Faso/epidemiología , Esquema de Medicación , Farmacorresistencia Microbiana , Femenino , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Mycobacterium/clasificación , Mycobacterium tuberculosis/aislamiento & purificación , Esputo/microbiología , Tuberculosis Resistente a Múltiples Medicamentos/epidemiología , Tuberculosis Pulmonar/microbiologíaRESUMEN
As part of the National Tuberculosis Program (NTP), a quality control of the slides (search of acido-fast-bacilli in the sputa) of the Treatment and Diagnosis Centers (TDC) forming the National Laboratory Network was carried out in 1996. 60 TDC of the 165 TDC (36%) had been controlled according to the system of double reading of the smears. The global concordance of the results in the 60 TDC is satisfactory since it was of 94%. Reliability of smears positive was of 83%. For the negative smears reliability, 14% of the TDC had a low or insufficient level. A good quality of smears was observed in 40% of the centers. The TDC that had both positive and negative reliability at 100% were 23 (38%) of which 13 had good quality of smears. Those were especially found in Antananarivo, Toliara, Fianarantsoa and Mahajanga.
Asunto(s)
Técnicas Bacteriológicas/normas , Laboratorios/normas , Microscopía/normas , Esputo/microbiología , Tuberculosis/diagnóstico , Reacciones Falso Negativas , Reacciones Falso Positivas , Humanos , Madagascar , Garantía de la Calidad de Atención de Salud/organización & administración , Control de Calidad , Método Simple Ciego , Manejo de Especímenes/normas , Tuberculosis/microbiologíaRESUMEN
Seroreactivity to Toxoplasma gondii (Tg) and to Cytomegalovirus (Cmv) was compared between symptomatic HIV-infected patients (40 with pulmonary tuberculosis and 38 with AIDS) and HIV-seronegative patients (40 tuberculosis patients and 30 healthy patients), in an urban area of Burkina Faso. Prevalence of IgG antibodies to Tg antigens (> 50.0%) did not differ amongst the four groups, but tuberculosis HIV+ patients and AIDS patients showed more higher titers of Tg antibodies more often than healthy patients (p < 0.05 and p < 0.005, respectively). Prevalence of specific IgG to Cmv was higher in tuberculosis HIV-seronegative patients (97.5%) and in AIDS patients (100%) than in healthy patients (82%; p < 0.03 and p < 0.001, respectively). Higher Cmv antibodies titers were found in relation to AIDS but also to tuberculosis. Tuberculosis HIV+ as tuberculosis HIV-patients showed higher Cmv antibodies titers than healthy patients (p < 0.002 and < 0.02 respectively). These data emphasize the need for taking into account the risk of Tg reactivation during the follow-up of HIV infected patients in Burkina Faso and suggest possible relationships between Cmv and tuberculosis reactivations.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/inmunología , Anticuerpos Antiprotozoarios/sangre , Anticuerpos Antivirales/sangre , Citomegalovirus/inmunología , Toxoplasma/inmunología , Tuberculosis Pulmonar/inmunología , Adulto , Animales , Burkina Faso , Femenino , Anticuerpos Anti-VIH/sangre , VIH-1/inmunología , VIH-2/inmunología , Humanos , Masculino , Persona de Mediana EdadRESUMEN
La double infection du VIH et de la tuberculose en Afrique de l'Ouest connait aujourd'hui une augmentation considerable. Ainsi une etude a ete menee en vue d'evaluer le degre d'atteinte immunitaire des patients seropositifs lors du diagnostic de la tuberculose ; d'ameliorer la definition du SIDA chez les patients et de proposer les marqueurs alternatifs aux marqueurs classiques d'immunodepression. Lors du diagnostic de la tuberculose seuls 33 pour cent des patients presentaient biologiquement du SIDA