Heteroresistance to rifampicin & isoniazid in clinical samples of patients with presumptive drug-resistant tuberculosis in Central India.

Background & objectives: A combination of resistant and susceptible Mycobacterium tuberculosis (MTB) isolated from clinical specimens is referred to as heteroresistance. Heteroresistance leads to difficulties in drug resistance testing and may adversely affect treatment outcomes. The present study estimated the proportion of heteroresistance among MTB in clinical samples of presumptive drug-resistant tuberculosis (TB) patients in Central India. Methods: A retrospective analysis of data generated from line probe assay (LPA) at a tertiary care hospital in Central India between January 2013 and December 2018 was carried out. A heteroresistant MTB in a sample was indicated by the presence of both wild-type and mutant-type patterns on an LPA strip. Results: Data analysis was carried out on interpretable 11,788 LPA results. Heteroresistance in MTB was detected in 637 (5.4%) samples. Of these, heteroresistance in MTB was detected in 413 (64.8%), 163 (25.5%) and 61 (9.5%) samples with respect to rpoB, katG and inhA genes, respectively. Interpretation & conclusions: Heteroresistance is considered a preliminary step in the development of drug resistance. Delayed or suboptimal anti-tubercular therapy in patients with heteroresistance of MTB may elicit full clinical resistance and negatively impact the National TB Elimination Programme. Further studies are, however, needed to determine the impact of heteroresistance on treatment outcomes in individual patients.

NDM-beta-lactamase-1: Where do we stand?

Multidrug-resistant (MDR) Gram-negative bacilli (GNB) have been playing havoc in the field of nosocomial as well as community-acquired infections. Of particular concern are the carbapenem-resistant GNBs, belonging to Enterobacteriaceae and encoding for New Delhi metallo-beta-lactamase-1 (NDM-1) gene. These strains spread rapidly and horizontally in the population, thus exhibiting MDR traits as these can harbour several resistance encoding genes to almost all antimicrobial groups. Several predisposing factors are responsible towards its spread, viz. excessive antibiotic usage, improper aseptic conditions by healthcare workers, lack of awareness, abruptly discontinuing medication course, alternative medications and vector-borne factors contributing to the unchecked harbouring of these super bugs in India. Thus, a bugle call has already been sounded worldwide especially in India, where the country has taken serious cognizance to build up strategy via implementation of several national programs to combat antimicrobial resistance covering human, animal, agriculture and environmental aspects. As there is an exponential rise in variants of NDM-1 harbouring strains, molecular epidemiological investigations of these strains using genotyping techniques are of paramount importance for a better understanding of this rampant spread and curbing resistance thereafter. This review explores the urgent need to develop a cost-effective, rapid molecular assay, viz. the loop-mediated isothermal amplification method for field detection of MBL harbouring bacterial strains, especially NDM-1 and its variants, thus targeting specific carbapenemase genes at a grass root level even to the remote and rural regions of the country.

Evaluation of 'TBDetect' sputum microscopy kit for improved detection of Mycobacterium tuberculosis: a multi-centric validation study.

OBJECTIVES: The present study aimed to evaluate the performance of the 'TBDetect' kit-based bio-safe fluorescent microscopy filter (BioFM-Filter) microscopy in comparison with direct smear microscopy and culture for the detection of pulmonary tuberculosis (TB) in a multi-centric setting in India. METHODS: The TBDetect kit enables sputum concentration through filtration using the BioFM-Filter for improved and bio-safe smear microscopy. We evaluated the performance of the TBDetect kit in a six-site multi-centric validation study on sputum collected from 2086 presumptive TB patients. RESULTS: The combined positivity of TBDetect microscopy performed on these sputum samples was 20% (n = 417/2086) vs 16.1% of light-emitting diode fluorescence microscopy (LED-FM, n = 337/2086) and 16% of Ziehl Neelsen (ZN) smear microscopy (n = 333/2086). The increment in positivity of TBDetect over both LED-FM and ZN smears was significant (p < 0.001). The overall sensitivity of TBDetect for six sites was ~55% (202/367, 95% confidence interval (CI): 50, 60%) vs 52% (191/367, 95% CI: 47, 57%) for LED-FM (p 0.14) and 50.9% (187/367, 95% CI: 46, 56%) for ZN smear (p < 0.05), using Mycobacterium Growth Indicator Tube culture (MGIT, n = 1949, culture positive, n = 367) as the reference standard. A bio-safety evaluation at six sites confirmed efficient sputum disinfection by TBDetect; 99.95% samples (1873/1874) were sterile after 42 days of incubation. Scientists and technicians at the study sites indicated the ease of use and convenience of TBDetect microscopy during feedback. CONCLUSIONS: TBDetect added value to the smear microscopy test due to its improved performance, convenience and user safety. These findings indicate that equipment-free TBDetect technology has the potential to improve TB diagnosis in basic laboratory settings by leveraging on the existing nationwide network of designated microscopy centres and primary healthcare centres.

Sociodemographic profile of patients attending the integrated counseling and testing center at a government super-specialty hospital in Central India.

CONTEXT: The HIV epidemic continues to be a matter of concern worldwide. Integrated counseling and testing center (ICTC) is an opening wedge for HIV diagnosis and support services, especially to the high-risk groups. Counseling and testing is a cost-effective and simple way of reducing HIV transmission. AIMS: The aim of the study was to analyze the sociodemographic profiles of the ICTC attendees to evaluate the changing trends of HIV seropositivities over a period of 7 years. SETTINGS AND DESIGN: This was a retrospective study done in the ICTC housed in a tertiary care hospital at Bhopal. MATERIALS AND METHODS: All attendees in the period of 7 years were included. STATISTICAL ANALYSIS USED: percentages and proportions were calculated. RESULTS: There were 24,853 ICTC attendees from January 2009 to January 2016, of which 183 (6.41%) attendees were tested seropositive. There were 15,555 (62.5%) males and 9298 (37.5%) female attendees. Among 15,555 males, 151 (0.97%) were seropositive, and of 9298 females, 32 (0.34%) were seropositive. Of 151 seropositive males, 62 (41%) were in the age group of 19-30 years and 48 (31.7%) were in the age group of 31-40 years. Among the seropositive females, 9 (28.1%) were in the age group of 19-30 years and 10 (31.2%) were in the age group of 31-40 years. We observed a rise in total number of ICTC attendees from January 2009 to January 2016. The number of attendees increased to 4655 in 2013, of which 27 (0.58%) were seropositive, and by 2015, there were 4982 attendees with only 6 (0.12%) seropositives. CONCLUSION: Such rising trends of attendees and a steady decline in the seropositivity rates are encouraging signs, reflecting the contribution of the ICTC in creating awareness, and reducing the transmission of HIV among the population served.

Burden of baseline resistance of Mycobacterium tuberculosis to fluoroquinolones and second-line injectables in central India.

BACKGROUND: Drug-resistant TB is a serious public health problem in India. Pre-existing resistance to fluoroquinolones (FQs) and second-line injectable drugs (SLIDs) in strains of Mycobacterium tuberculosis (MTB) resistant to rifampicin (RIF) and/or isoniazid (INH) contributes to treatment failures and consequent transmission of drug-resistant TB. A baseline assessment of resistance of MTB to FQs and SLIDs may help guide policies to further improve management of drug-resistant TB in India. This study aims to determine the prevalence of resistance to FQs and SLIDs among MTB strains having RIF and/or INH resistance in central India. METHOD: A total of 1032 smear positive sputum samples were subjected to line probe assay (GenoType MTBDRsl version 2) to test for resistance to FQs and SLIDs, according to the integrated diagnostic algorithm of the revised national TB control programme. RESULTS: Of 1032 samples, 92 (8.91%) were not interpretable and hence excluded, 295 (31.38%) were resistant to FQs alone, 13 (1.38%) were resistant to SLIDs alone, 15 (1.59%) were resistant to both FQs as well as SLIDs and 617 (65.63%) were sensitive to both FQs and SLIDs. The most common mutations in gyrA and gyrB genes were observed at codons D94G and E540V, respectively. Mutations at codon A1401G in rrs genes and in the C-14 T region of eis genes were most frequently observed. CONCLUSION: High levels of FQ resistance points towards indiscriminate use of this class of drugs. Regulation for judicial use of FQs is an urgent requirement.

Sero-Occurrence of HBV/HCV Co-infection and Levels of Liver Enzymes among Patients at a Tertiary Care Hospital in Central India: a Pilot Study.

INTRODUCTION: Hepatitis B and C viral infections share common modes of transmission and account for a large proportion of liver disease burden across the globe. Patients with Hepatitis B (HBV) and Hepatitis C virus (HCV) co-infection may have more severe liver disease and are potentially at higher risk for developing hepatocellular carcinoma. The aim of this study was to assess the sero-occurrence of HBV/HCV co-infection by examining the medical records of tertiary care hospital patients in Central India and determine the extent of liver damage based on liver function tests (LFTs). METHODS: Patients with a positive test for HBV surface antigen (HBsAg) over a period of 10 years were identified from laboratory records in a tertiary care facility in central India. Records of 51,075 consecutive non-duplicate blood samples were then screened for a positive HBV and HCV tests. LFT, liver enzymes, and bilirubin data were also extracted. Means and standard deviations were determined for continuous variables, and the difference in means was compared using a independent samples t-test. Associations between HBV/HCV co-infection status and demographic variables were calculated using Pearson's Chi-squared test. A p-value less than 0.05 was considered statistically significant. RESULTS: In this study, 1674 (3.27%) screened patients were positive for HBsAg and the sero-occurrence of co-infection with HCV in HBsAg positive patients was reported in 28 individuals (1.67%). There was no significant gender difference for HBV/HCV co-infection (p>0.05). HBV/HCV co-infection was observed more frequently in the 31-60 year old age group (p=0.001). HBV/HCV co-infected patients had significantly higher levels of liver enzymes and bilirubin than those with HBsAg mono-infection (p=0.001). CONCLUSION: Liver function tests are potentially important predictors for HBV/HCV coinfection. Screening for HCV co-infection in HBsAg-positive patients is recommended in India. Detection of co-infection may enable timely preventive/therapeutic interventions aimed at preventing progression to hepatocellular carcinoma.

Host-targeted therapy for tuberculosis: Time to revisit the concept.

Tuberculosis (TB) is an important cause of morbidity and mortality worldwide. Every year millions of people die due to TB. Drug resistance has been a major factor that has obstructed successful control and treatment of TB. As the rate of spread of drug-resistant TB outpaces the rate of discovery of new anti-tubercular drugs, targeted therapy may provide a new approach to TB cure. In a scenario where drug resistance is spreading rapidly, and existing drugs regimens seem to be dwindling away, this review summarizes the concept of host-targeted therapy which may be the ray of hope for the effective management and control of the rapidly spreading drug-resistant TB (multidrug resistant and extensively drug resistant).

Provider reported barriers and solutions to improve testing among tuberculosis patients 'eligible for drug susceptibility test': A qualitative study from programmatic setting in India.

BACKGROUND: In a study conducted in Bhopal district (a setting with facility for molecular drug susceptibility testing (DST)) located in central India in 2014-15, we found high levels of pre-diagnosis attrition among patients with presumptive multi drug-resistant tuberculosis (MDR-TB)-meaning TB patients who were eligible for DST, were not being tested. OBJECTIVES: In this study, we explored the health care provider perspectives into barriers and suggested solutions for improving DST. METHODS: This was a descriptive qualitative study. One to one interviews (n = 10) and focus group discussions (n = 2) with experienced key informants involved in programmatic management of DR-TB were conducted in April 2017. Manual descriptive thematic analysis was performed. RESULTS: The key barriers reported were a) lack of or delay in identification of patients eligible for DST because of using treatment register as the source for identifying patients b) lack of assured specimen transport after patient identification and c) lack of tracking. Extra pulmonary TB patients were not getting identified as eligible for DST. Solutions suggested by the health care providers were i) generation of unique identifier at identification in designated microscopy center (DMC), immediate intimation of unique identifier to district and regular monitoring by senior TB laboratory and senior treatment supervisors of patients eligible for DST that were missed; ii) documentation of unique identifier at each step of cascade; iii) use of human carriers/couriers to transport specimen from DMCs especially in rural areas; and iv) routine entry of all presumptive extra-pulmonary TB specimen, as far as possible, in DMC laboratory register. CONCLUSION: Lack of assured specimen transport and lack of accountability for tracking patient after identification and referral were the key barriers. The identification of patients eligible for DST among microbiologically confirmed TB at the time of diagnosis and among clinically confirmed TB at the time of treatment initiation is the key. Use of unique identifier at identification and its use to ensure cohort wise tracking has to be complemented with specimen transport support and prompt feedback to the DMC. The study has implications to improve detection of MDR-TB among diagnosed/notified TB patients.

Prevalence of hepatitis B and hepatitis C virus co-infection in India: A systematic review and meta-analysis.

Hepatitis B virus (HBV) and hepatitis C virus (HCV) have several important similarities including worldwide distribution, hepato-tropism, similar modes of transmission and the ability to induce chronic infection that may lead to liver cirrhosis and hepatocellular carcinoma. Since both viruses are individually known to cause the pathologies mentioned above, co-infection with both HBV and HCV would be expected to be linked with higher morbidity as well as mortality and impact healthcare resource utilisation. Precise estimate of the prevalence of HBV/HCV co-infection would be needed to formulate policy decisions and plan communal health interventions. This systematic review and meta-analysis, therefore, aims to understand the prevalence of HBV and HCV co-infection in India based on the available literature. Following PRISMA guidelines, primary studies reporting the prevalence of HBV/HCV co-infection in India were retrieved through searches conducted in PubMed, Google SCHOLAR, Medline, Cochrane Library, WHO reports, Indian and International journals online. All online searches were conducted between December 2016 and February 2017. Meta-analysis was carried out using StatsDirect statistical software. Thirty studies published between 2000 and 2016 conducted across six regions of India were included in this review. The pooled HBV/HCV co-infection prevalence rate across the thirty studies was 1.89% (95% confidence intervals [CI] = 1.2%-2.4%). A high heterogeneity was observed between prevalence estimates. The HBV/HCV co-infection prevalence in different subgroups varied from 0.02% (95% CI = 0.0019%-0.090%) to 3.2% (95% CI = 1.3%-5.9%). The pooled prevalence of HBV/HCV co-infection in India was found to be 1.89%. This systematic review and meta-analysis revealed high prevalence of HBV/HCV co-infection in chronic liver patients, followed by HIV-positive patients, and then followed by persons who inject drugs and kidney disease patients.

Line probe assay for detection of Mycobacterium tuberculosis complex: An experience from Central India.

BACKGROUND & OBJECTIVES: Mycobacterium tuberculosis complex may sometimes not be detected in sputum samples of suspected multidrug-resistant tuberculosis (MDR-TB) patients by line probe assay (LPA) even though they are smear positive for acid-fast bacilli (AFB). This retrospective analysis was attempted to understand and document our experience with LPA for detection of M. tuberculosis complex and diagnosis of MDR-TB under programmatic conditions. METHODS: One thousand two hundred and ninety four sputum samples of MDR-TB suspects that were smear positive for AFB, and received from February to November 2013, were tested by LPA for the presence of M. tuberculosis complex and resistance to isoniazid (INH) and rifampicin as per the diagnostic mandate of an accredited reference laboratory. As per the mandate, those samples that were negative for M. tuberculosis complex were cultured, and the growth again tested by LPA. A retrospective analysis of the results was carried out. RESULTS: M. tuberculosis complex could be detected in 1217 (94.04%) but not in 77 (5.9%) of smear-positive sputum samples. Of the 1217 positive samples, 232 (19.1%) were MDR, 130 (10.6%) were rifampicin monoresistant and 101 (8.3%) were INH monoresistant. Seven hundred and fifty four (61.9%) strains were found to be pansensitive. Overall, 5.1 per cent of the sputum samples were negative for M. tuberculosis complex by LPA and culture. In at least 10 (0.77%) sputum samples smear positive for AFB, M. tuberculosis complex could not be identified by LPA though M. tuberculosis was present, as evidenced by culture positivity. INTERPRETATION & CONCLUSIONS: LPA is a robust technique for diagnosis of drug-resistant TB that has provided the basis for rapid and effective control of drug-resistant TB in India. While the reasons for concomitantly negative LPA and culture results of smear-positive sputum samples from MDR-TB suspects may be many, the possible presence of non-tubercular mycobacteria in these samples and the likelihood of inappropriate therapy in these patients cannot be ruled out. Addition of culture to the diagnostic algorithm may enhance the diagnostic yield.

Spoligotype defined lineages of Mycobacterium tuberculosis and drug resistance: Merely a casual correlation?

Drug-resistant tuberculosis (TB) is a major challenge to TB control strategy worldwide. Analysis of genetic polymorphism among drug resistant Mycobacterium tuberculosis (MTB) strains may help provide some insight into the transmission dynamics of these strains. Spoligotyping is a widely used technique to identify genetic polymorphism, based on 43 known spacers interspersed between direct repeat regions. Considerable work has been done in various parts of the world using this technique to identify and analyse the polymorphic nature of MTB. Many studies have been carried out to determine the association of drug resistance with spoligotype defined lineages, and much data has been produced over the years. New information continues to be generated. This review aims to put together the findings of relevant studies in an attempt to understand the correlation of drug resistance with spoligotype defined lineages of MTB. This would help provide a perspective of the available data that can be used as a starting point to understand the molecular epidemiology of drug resistant TB.

Trends in spoligotype patterns of Mycobacterium tuberculosis strains in central India.

This study aims to understand trends in spoligotype patterns of Mycobacterium tuberculosis (MTB) in Central India. Elucidation of these trends may provide baseline information to understand the transmission dynamics of strains of MTB in the region. Spoligotyping was carried out on 340 MTB strains isolated from clinical samples received from 2007 to 2011. The prevalence of ST26/CAS1_Del, ST11/EAI3_IND, ST288/CAS2, ST25/CAS1_Del and Beijing lineages showed waxing and waning trends. ST26/CAS1_Del and ST11/EAI3_IND lineages were consistently present and were predominant. Well-established lineages showed a consistent presence in the community. New orphan lineages appeared to be less capable of establishing themselves.

Public health relevance of non-tuberculous mycobacteria among AFB positive sputa.

BACKGROUND: Sputum smear microscopy for acid fast bacilli (AFB) is used by most public health programmes to detect tuberculosis. While most AFB in countries endemic for tuberculosis are Mycobacterium tuberculosis (MTB), some may also be non-tuberculous mycobacteria (NTM). The inability to differentiate NTM from MTB by sputum smear microscopy may lead to erroneous diagnoses of tuberculosis, leading in turn to inappropriate therapy. METHODS: This was a retrospective study of consecutive sputum samples received from November 2013 to March 2015 in the Department of Microbiology, Bhopal Memorial Hospital & Research Centre, Bhopal, India. Samples underwent smear microscopy, line probe assay (LPA) for MTB complex, culture, biochemical tests and LPA for NTM. RESULTS: Of 4095 sputum samples, 2886 were AFB smear positive (70.5%). Of these, MTB complex was detected in 2611 (90.5%) samples by LPA. Of the remaining 275 samples, 47 grew AFB on culture. Nine strains belonged to the MTB complex. The remaining 38 (1.3%) were NTM, and could be speciated in 26 strains; 14 (53.8 %) were M. abscessus; 10 (38.4%) M. intracellulare, one (3.8%) M. kansasii and one (3.8%) M. fortuitum. The remaining 12 NTM could not be speciated. CONCLUSION: NTM were present in at least 1.3% of all smear positive samples. It is important for public health programs to recognize the avoidable burden on logistics, infrastructure and finances caused by this. Detection and quantification of this burden would help design an appropriate strategy for optimal tuberculosis control.

Genetic diversity of Mycobacterium tuberculosis isolates from central India.

BACKGROUND & OBJECTIVES: There is a paucity of data available on genetic biodiversity of Mycobacterium tuberculosis isolates from central India. The present study was carried out on isolates of M. tuberculosis cultured from diagnostic clinical samples of patients from Bhopal, central India, using spoligotyping as a method of molecular typing. METHODS: DNA was extracted from 340 isolates of M. tuberculosis from culture, confirmed as M. tuberculosis by molecular and biochemical methods and subjected to spoligotyping. The results were compared with the international SITVIT2 database. RESULTS: Sixty five different spoligo international type (SIT) patterns were observed. A total of 239 (70.3%) isolates could be clustered into 25 SITs. The Central Asian (CAS) and East African Indian (EAI) families were found to be the two major circulating families in this region. SIT26/CAS1_DEL was identified as the most predominant type, followed by SIT11/EAI3_IND and SIT288/CAS[2]. Forty (11.8%) unique (non-clustered) and 61 (17.9%) orphan isolates were identified in the study. There was no significant association of clustering with clinical and demographic characteristics of patients. INTERPRETATION & CONCLUSIONS: Well established SITs were found to be predominant in our study. SIT26/CAS1_DEL was the most predominant type. However, the occurrence of a substantial number of orphan isolates may indicate the presence of active spatial and temporal evolutionary dynamics within the isolates of M. tuberculosis.

Acute Monoarthritis of the Wrist Joint: Tuberculosis or Not?

Background Extrapulmonary tuberculosis (EPTB) is known to have many and varied presentations. However, isolated involvement of bone with tubercular infection is uncommon. The clinical features of such infections are known to mimic chronic pyogenic osteomyelitis, Brodie abscess, or tumors, but not acute monoarthritis. Case Description We describe here an unusual case of tuberculous osteomyelitis that mimicked features of acute monoarthritis of the wrist joint. Literature Review Extraspinal tuberculous osteomyelitis is rare and comprises only about 2 to 3% of all cases of osteoarticular tuberculosis, with the hip and knee joints being the most commonly involved. An extensive literature review did not show any published report of tuberculous osteomyelitis presenting as acute monoarthritis of the wrist joint. Clinical Relevance This case underlines the importance of making EPTB an important differential diagnosis even in cases with clinical features that are completely inconsistent with tubercular infections.

Frequency of mutations in rifampicin and isoniazid resistant isolates of M. tuberculosis: an analysis from Central India.

BACKGROUND: The spread of drug-resistant tuberculosis has challenged tuberculosis control strategies globally. The present study aims to analyze the frequency of mutations in rpoB, katG and inhA genes in strains of M. tuberculosis complex (MTBC) circulating in Central India. It is anticipated that the findings may provide a starting point to understand the evolutionary success of drug-resistant strains of MTBC in this region. METHODS: Line probe assay was carried out on 720 consecutive sputum samples of MDR suspects from June 2012 to May 2013. Mutation frequencies in the rpoB, katG and inhA genes were analyzed. RESULTS: Mutations were identified in 269 (37.6%) samples, as follows: 55 (7.6%) samples had mutations conferring resistance to only isoniazid, 84 (11.6%) had mutations conferring resistance to only rifampicin and 130 (18%) isolates had mutations conferring resistance to both isoniazid and rifampicin. The most frequent mutation in the rpoB gene was at codon S531L, seen in 141 (19.5%) isolates. The most frequent mutation in the katG gene was at codon S315T1, seen in 151 (20.9%) isolates; and in the inhA gene at codon C15T, seen in 21 (2.9%) isolates. Some unidentified mutations were also observed. CONCLUSION: The patterns and the frequency of the mutations identified in this study indicate the most frequent mutations at S531L codon in the rpoB gene, S315T1 codon in the katG gene and C15T codon in the promoter region of the inhA gene. Controlling the emergence and spread of MDR TB requires an understanding of the evolution of these mutations.