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1.
Open Forum Infect Dis ; 6(7): ofz221, 2019 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-31289727

RESUMEN

Mycobacterium abscessus disease is particularly challenging to treat, given the intrinsic drug resistance of this species and the limited data on which recommendations are based, resulting in a greater reliance on expert opinion. We address several commonly encountered questions and management considerations regarding pulmonary Mycobacterium abscessus disease, including the role of subspecies identification, diagnostic criteria for determining disease, interpretation of drug susceptibility test results, approach to therapy including the need for parenteral antibiotics and the role for new and repurposed drugs, and the use of adjunctive strategies such as airway clearance and surgical resection.

3.
Thorac Surg Clin ; 29(1): 85-94, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30454925

RESUMEN

Although less common as causes of musculoskeletal infection than pyogenic bacteria, both Mycobacterium tuberculosis and nontuberculous mycobacteria can infect bones and joints. Although tuberculous arthritis and osteomyelitis have been recognized for millennia, infections caused by nontuberculous mycobacteria are being identified more often, likely because of a more susceptible host population and improvements in diagnostic capabilities. Despite advances in modern medicine, mycobacterial infections of the musculoskeletal system remain particularly challenging to diagnose and manage. This article discusses clinical manifestations of musculoskeletal infections caused by Mycobacterium tuberculosis and nontuberculous mycobacteria. Pathogenesis, unique risk factors, and diagnostic and therapeutic approaches are reviewed.


Asunto(s)
Artritis Infecciosa/terapia , Enfermedades Óseas Infecciosas/terapia , Infecciones por Mycobacterium/terapia , Mycobacterium tuberculosis/aislamiento & purificación , Micobacterias no Tuberculosas/aislamiento & purificación , Artritis Infecciosa/diagnóstico , Artritis Infecciosa/microbiología , Enfermedades Óseas Infecciosas/diagnóstico , Enfermedades Óseas Infecciosas/microbiología , Humanos , Infecciones por Mycobacterium/diagnóstico , Infecciones por Mycobacterium/microbiología , Factores de Riesgo
4.
Curr Opin HIV AIDS ; 13(6): 478-485, 2018 11.
Artículo en Inglés | MEDLINE | ID: mdl-30286039

RESUMEN

PURPOSE OF REVIEW: This review aims to describe the key principles in treatment of drug-resistant tuberculosis (TB) in people living with HIV, including early access to timely diagnostics, linkage into care, TB treatment strategies including the use of new and repurposed drugs, co-management of HIV disease, and treatment complications and programmatic support to optimize treatment outcomes. These are necessary strategies to decrease the likelihood of poor treatment outcomes including lower treatment completion rates and higher mortality. RECENT FINDINGS: Diagnosis of drug-resistant TB is the gateway into care; yet understanding the utility and the limitations of genotypic methods in this population is necessary. The principles of TB treatment in HIV-infected individuals are similar to those without HIV co-infection, with few exceptions. However, adverse effects with potential significant morbidity may emerge during treatment, and timely antiretroviral therapy is essential to improve mortality in this patient population. Emerging data on the use of new and repurposed drugs and short course multidrug-resistant TB regimens and adherence strategies benefiting this population are reviewed. SUMMARY: The clinical complexity of co-managing drug-resistant TB and HIV, and the higher rate of poor treatment outcomes in this population demand careful clinical management strategies, and multidisciplinary and comprehensive programmatic interventions to optimize treatment success in this vulnerable group.


Asunto(s)
Antituberculosos/administración & dosificación , Infecciones por VIH/complicaciones , Mycobacterium tuberculosis/efectos de los fármacos , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Animales , Coinfección/tratamiento farmacológico , Infecciones por VIH/virología , Humanos , Mycobacterium tuberculosis/fisiología , Resultado del Tratamiento , Tuberculosis Resistente a Múltiples Medicamentos/complicaciones , Tuberculosis Resistente a Múltiples Medicamentos/microbiología
6.
Curr Treat Options Infect Dis ; 10(2): 169-181, 2018 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-30662371

RESUMEN

Purpose of review: Non-tuberculous mycobacterial [NTM] infections in the hospital setting are a complex and often challenging entity. The goal of this review is to discuss diagnostic and treatment strategies for established as well as emerging nosocomial NTM infections. Recent findings: NTM outbreaks have been documented in a variety of hospital settings. Contamination of medical devices or aqueous solutions is often implicated in the spread of infection. More recently, the slow grower M. chimaera has been reported in the setting of contaminated heater-cooler devices used for cardiopulmonary bypass and extracorporeal membrane oxygenation. In addition, increases in medical tourism for cosmetic surgery have led to outbreaks of rapidly growing mycobacteria. Summary: Diagnosis and treatment of nosocomial NTM pose many challenges for the clinician. Surgical resection or debridement as well as combination antimycobacterial therapy are a mainstay in therapeutic management. Strict infection control and prevention practices are critical to the identification and cessation of outbreaks.

7.
BMJ Case Rep ; 20172017 May 22.
Artículo en Inglés | MEDLINE | ID: mdl-28536227

RESUMEN

A 26-year-old female from India presented with progressive, unremitting low back pain for over 1 year. She had been treated unsuccessfully for left-sided sacroiliitis, pelvic floor dysfunction, ankylosing spondylitis and seronegative spondyloarthritis. MRI lumbar spine showed a Schmorl node with surrounding marrow oedema at L4, the relevance of which is not clear in literature. One year after initial presentation, a biopsy of this lesion revealed culture positive diagnosis of spinal tuberculosis. Despite advances in imaging, delayed diagnosis is not uncommon in spinal tuberculosis (TB). In our case, it was also attributed to an unknown early lesion: Schmorl node with surrounding oedema. Any association of this lesion with spinal TB has previously not been reported.


Asunto(s)
Edema/diagnóstico , Degeneración del Disco Intervertebral/diagnóstico , Desplazamiento del Disco Intervertebral/diagnóstico , Tuberculosis de la Columna Vertebral/diagnóstico , Adulto , Dolor de Espalda/etiología , Diagnóstico Tardío , Edema/complicaciones , Femenino , Humanos , Degeneración del Disco Intervertebral/complicaciones , Desplazamiento del Disco Intervertebral/complicaciones , Tuberculosis de la Columna Vertebral/complicaciones
8.
Infect Dis Clin North Am ; 31(2): 369-382, 2017 06.
Artículo en Inglés | MEDLINE | ID: mdl-28292541

RESUMEN

Although less common as causes of musculoskeletal infection than pyogenic bacteria, both Mycobacterium tuberculosis and nontuberculous mycobacteria can infect bones and joints. Although tuberculous arthritis and osteomyelitis have been recognized for millennia, infections caused by nontuberculous mycobacteria are being identified more often, likely because of a more susceptible host population and improvements in diagnostic capabilities. Despite advances in modern medicine, mycobacterial infections of the musculoskeletal system remain particularly challenging to diagnose and manage. This article discusses clinical manifestations of musculoskeletal infections caused by Mycobacterium tuberculosis and nontuberculous mycobacteria. Pathogenesis, unique risk factors, and diagnostic and therapeutic approaches are reviewed.


Asunto(s)
Enfermedades Musculoesqueléticas/diagnóstico , Enfermedades Musculoesqueléticas/microbiología , Infecciones por Micobacterias no Tuberculosas/diagnóstico , Micobacterias no Tuberculosas/aislamiento & purificación , Tuberculosis Osteoarticular/diagnóstico , Artritis Infecciosa/diagnóstico , Artritis Infecciosa/tratamiento farmacológico , Artritis Infecciosa/microbiología , Femenino , Humanos , Inmunosupresión/efectos adversos , Masculino , Enfermedades Musculoesqueléticas/fisiopatología , Enfermedades Musculoesqueléticas/terapia , Infecciones por Micobacterias no Tuberculosas/microbiología , Mycobacterium tuberculosis/efectos de los fármacos , Mycobacterium tuberculosis/aislamiento & purificación , Micobacterias no Tuberculosas/efectos de los fármacos , Osteomielitis/diagnóstico , Osteomielitis/tratamiento farmacológico , Osteomielitis/microbiología , Tenosinovitis/diagnóstico , Tenosinovitis/tratamiento farmacológico , Tenosinovitis/microbiología , Tuberculosis de la Columna Vertebral/diagnóstico , Tuberculosis de la Columna Vertebral/tratamiento farmacológico , Tuberculosis de la Columna Vertebral/microbiología
10.
Thorax ; 70(12): 1181-8, 2015 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-26506854

RESUMEN

BACKGROUND: In Africa, fewer than half of patients receiving therapy for multidrug-resistant TB (MDR TB) are successfully treated, with poor outcomes reported for HIV-coinfected patients. METHODS: A standardised second-line drug (SLD) regimen was used in a non-governmental organisation-Ministry of Health (NGO-MOH) collaborative community and hospital-based programme in Ethiopia that included intensive side effect monitoring, adherence strategies and nutritional supplementation. Clinical outcomes for patients with at least 24 months of follow-up were reviewed and predictors of treatment failure or death were evaluated by Cox proportional hazards models. RESULTS: From February 2009 to December 2014, 1044 patients were initiated on SLD. 612 patients with confirmed or presumed MDR TB had ≥ 24 months of follow-up, 551 (90.0%) were confirmed and 61 (10.0%) were suspected MDR TB cases. 603 (98.5%) had prior TB treatment, 133 (21.7%) were HIV coinfected and median body mass index (BMI) was 16.6. Composite treatment success was 78.6% with 396 (64.7%) cured, 85 (13.9%) who completed treatment, 10 (1.6%) who failed, 85 (13.9%) who died and 36 (5.9%) who were lost to follow-up. HIV coinfection (adjusted HR (AHR): 2.60, p<0.001), BMI (AHR 0.88/kg/m(2), p=0.006) and cor pulmonale (AHR 3.61, p=0.003) and confirmed MDR TB (AHR 0.50, p=0.026) were predictive of treatment failure or death. CONCLUSIONS: We report from Ethiopia the highest MDR TB treatment success outcomes so far achieved in Africa, in a setting with severe resource constraints and patients with advanced disease. Intensive treatment of adverse effects, nutritional supplementation, adherence interventions and NGO-MOH collaboration were key strategies contributing to success. We argue these approaches should be routinely incorporated into programmes.


Asunto(s)
Tuberculosis Resistente a Múltiples Medicamentos/terapia , Adulto , Coinfección , Etiopía , Femenino , Infecciones por VIH/epidemiología , Humanos , Masculino , Cumplimiento de la Medicación , Modelos de Riesgos Proporcionales , Resultado del Tratamiento , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Tuberculosis Resistente a Múltiples Medicamentos/epidemiología , Tuberculosis Resistente a Múltiples Medicamentos/mortalidad , Adulto Joven
11.
PLoS One ; 9(9): e108035, 2014.
Artículo en Inglés | MEDLINE | ID: mdl-25238411

RESUMEN

Sputum cultures are an important tool in monitoring the response to tuberculosis treatment, especially in multidrug-resistant tuberculosis. There has, however, been little study of the effect of treatment regimen composition on culture conversion. Well-designed clinical trials of new anti-tuberculosis drugs require this information to establish optimized background regimens for comparison. We conducted a retrospective cohort study to assess whether the use of an aggressive multidrug-resistant tuberculosis regimen was associated with more rapid sputum culture conversion. We conducted Cox proportional-hazards analyses to examine the relationship between receipt of an aggressive regimen for the 14 prior consecutive days and sputum culture conversion. Sputum culture conversion was achieved in 519 (87.7%) of the 592 patients studied. Among patients who had sputum culture conversion, the median time to conversion was 59 days (IQR: 31-92). In 480 patients (92.5% of those with conversion), conversion occurred within the first six months of treatment. Exposure to an aggressive regimen was independently associated with sputum culture conversion during the first six months of treatment (HR: 1.36; 95% CI: 1.10, 1.69). Infection with human immunodeficiency virus (HR 3.36; 95% CI: 1.47, 7.72) and receiving less exposure to tuberculosis treatment prior to the individualized multidrug-resistant tuberculosis regimen (HR: 1.58; 95% CI: 1.28, 1.95) were also independently positively associated with conversion. Tachycardia (HR: 0.77; 95% CI: 0.61, 0.98) and respiratory difficulty (HR: 0.78; 95% CI: 0.62, 0.97) were independently associated with a lower rate of conversion. This study is the first demonstrating that the composition of the multidrug-resistant tuberculosis treatment regimen influences the time to culture conversion. These results support the use of an aggressive regimen as the optimized background regimen in trials of new anti-TB drugs.


Asunto(s)
Antituberculosos/uso terapéutico , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Adulto , Antituberculosos/administración & dosificación , Protocolos Clínicos , Femenino , Humanos , Masculino , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Tiempo , Tuberculosis Resistente a Múltiples Medicamentos/diagnóstico
12.
PLoS One ; 8(3): e58664, 2013.
Artículo en Inglés | MEDLINE | ID: mdl-23516529

RESUMEN

RATIONALE: A better understanding of the composition of optimal treatment regimens for multidrug-resistant tuberculosis (MDR-TB) is essential for expanding universal access to effective treatment and for developing new therapies for MDR-TB. Analysis of observational data may inform the definition of an optimized regimen. OBJECTIVES: This study assessed the impact of an aggressive regimen-one containing at least five likely effective drugs, including a fluoroquinolone and injectable-on treatment outcomes in a large MDR-TB patient cohort. METHODS: This was a retrospective cohort study of patients treated in a national outpatient program in Peru between 1999 and 2002. We examined the association between receiving an aggressive regimen and the rate of death. MEASUREMENTS AND MAIN RESULTS: In total, 669 patients were treated with individualized regimens for laboratory-confirmed MDR-TB. Isolates were resistant to a mean of 5.4 (SD 1.7) drugs. Cure or completion was achieved in 66.1% (442) of patients; death occurred in 20.8% (139). Patients who received an aggressive regimen were less likely to die (crude hazard ratio [HR]: 0.62; 95% CI: 0.44,0.89), compared to those who did not receive such a regimen. This association held in analyses adjusted for comorbidities and indicators of severity (adjusted HR: 0.63; 95% CI: 0.43,0.93). CONCLUSIONS: The aggressive regimen is a robust predictor of MDR-TB treatment outcome. TB policy makers and program directors should consider this standard as they design and implement regimens for patients with drug-resistant disease. Furthermore, the aggressive regimen should be considered the standard background regimen when designing randomized trials of treatment for drug-resistant TB.


Asunto(s)
Antituberculosos/uso terapéutico , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Tuberculosis Resistente a Múltiples Medicamentos/mortalidad , Análisis de Varianza , Femenino , Humanos , Masculino , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento
13.
Am J Respir Crit Care Med ; 186(10): 953-64, 2012 Nov 15.
Artículo en Inglés | MEDLINE | ID: mdl-22983960

RESUMEN

The management of children with drug-resistant tuberculosis (DR-TB) is challenging, and it is likely that in many places, the roll-out of molecular diagnostic testing will lead to more children being diagnosed. There is a limited evidence base to guide optimal treatment and follow-up in the pediatric population; in existing DR-TB guidelines, the care of children is often relegated to small "special populations" sections. This article seeks to address this gap by providing clinicians with practical advice and guidance. This is achieved through review of the available literature on pediatric DR-TB, including research studies and international guidelines, combined with consensus opinion from a team of experts who have extensive experience in the care of children with DR-TB in a wide variety of contexts and with varying resources. The review covers treatment initiation, regimen design and treatment duration, management of comorbid conditions, treatment monitoring, adverse events, adherence promotion, and infection control, all within a multidisciplinary environment.


Asunto(s)
Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Antituberculosos/administración & dosificación , Antituberculosos/efectos adversos , Niño , Terapia por Observación Directa , Monitoreo de Drogas , Humanos , Tuberculosis Resistente a Múltiples Medicamentos/complicaciones , Tuberculosis Resistente a Múltiples Medicamentos/diagnóstico , Tuberculosis Resistente a Múltiples Medicamentos/microbiología
14.
Bull World Health Organ ; 90(1): 63-6, 2012 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-22271966

RESUMEN

PROBLEM: The category II retreatment regimen for management of tuberculosis in previously treated patients was first introduced in the early 1990s. It consists of 8 months of total therapy with the addition of streptomycin to standard first-line medications. A review of 6500 patients on category II therapy in Georgia showed poor outcomes and high rates of streptomycin resistance. APPROACH: The National Tuberculosis Program used an evidence-based analysis of national data to convince policy-makers that category II therapy should be eliminated from national guidelines in Georgia. LOCAL SETTING: The World Health Organization tuberculosis case-notification rate in Georgia is 102 per 100,000 population. All patients receive culture and drug susceptibility testing as a standard part of tuberculosis diagnosis. In 2009, routine surveillance found multidrug-resistant tuberculosis in 10.6% of newly diagnosed patients and 32.5% of previously treated cases. RELEVANT CHANGES: Category II retreatment regimen is no longer used in Georgia. Treatment is guided by results of drug susceptibility testing--using rapid, molecular tests where possible--for all previously treated tuberculosis patients. LESSONS LEARNT: There was little resistance to policy change because the review was initiated and led by the National Tuberculosis Program. This experience can serve as a successful model for other countries to make informed decisions about the use of category II therapy.


Asunto(s)
Toma de Decisiones , Política de Salud/tendencias , Guías de Práctica Clínica como Asunto , Evaluación de Programas y Proyectos de Salud , Tuberculosis Pulmonar/epidemiología , Antituberculosos/uso terapéutico , Georgia (República)/epidemiología , Humanos , Vigilancia de la Población , Resultado del Tratamiento , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/tratamiento farmacológico
15.
J Infect Dis ; 204 Suppl 4: S1102-9, 2011 Nov 15.
Artículo en Inglés | MEDLINE | ID: mdl-21996692

RESUMEN

Clinical and logistic systems to support the timely diagnosis of tuberculosis are currently not preventing large numbers of tuberculosis deaths in South Africa. Context-appropriate systems for the diagnosis of tuberculosis are entirely dependent on effective and responsive management of human resources and an uninterrupted supply of clinical materials. Attention to these components of the tuberculosis program is urgently needed before new diagnostic technologies can be expected to impact on tuberculosis mortality in resource constrained settings.


Asunto(s)
Tuberculosis/diagnóstico , Adulto , Niño , Técnicas de Laboratorio Clínico , Prestación de Atención de Salud , Países en Desarrollo , Humanos , Laboratorios de Hospital/organización & administración , Laboratorios de Hospital/provisión & distribución , Personal de Laboratorio Clínico/organización & administración , Personal de Laboratorio Clínico/provisión & distribución , Sudáfrica , Esputo/microbiología
16.
J Neurovirol ; 17(3): 288-90, 2011 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-21487835

RESUMEN

Natalizumab (Tysabri, Biogen Idec and Elan Pharmaceuticals) is a monoclonal antibody approved for use in patients with relapsing multiple sclerosis (MS) as well as moderate to severe Crohn's disease. We report the first case of a patient with a history of MS, on monthly natalizumab, who developed HSV-2 meningitis. We discuss the mechanism of action of natalizumab and review what is known about the reactivation of herpes infection in association with this medication. The question of herpes simplex virus (HSV) and varicella zoster virus (VZV) prophylaxis for patients is raised.


Asunto(s)
Anticuerpos Monoclonales , Enfermedad de Crohn/tratamiento farmacológico , Herpes Simple/inducido químicamente , Meningitis Viral/inducido químicamente , Esclerosis Múltiple Recurrente-Remitente/tratamiento farmacológico , Anticuerpos Monoclonales/administración & dosificación , Anticuerpos Monoclonales Humanizados , Contraindicaciones , Enfermedad de Crohn/inmunología , Enfermedad de Crohn/patología , Femenino , Herpes Simple/inmunología , Herpes Simple/virología , Herpesvirus Humano 2/inmunología , Herpesvirus Humano 3/inmunología , Humanos , Integrina alfa4/inmunología , Integrina alfa4/metabolismo , Activación de Linfocitos/efectos de los fármacos , Linfocitos/inmunología , Linfocitos/patología , Linfocitos/virología , Meningitis Viral/inmunología , Meningitis Viral/virología , Persona de Mediana Edad , Esclerosis Múltiple Recurrente-Remitente/inmunología , Esclerosis Múltiple Recurrente-Remitente/patología , Natalizumab
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