5 курс / Пульмонология и фтизиатрия / Clinical_Tuberculosis_Friedman_Lloyd_N_,_Dedicoat

often present, but it is in the order of magnitude of an increased risk of 3 times102,103; there have been much higher estimates. A 10-year retrospective study of copper miners from what is now Zambia found that there was a 26-fold increase in silicotic miners (2.89%/year) compared to nonsilicotic miners (0.11%/year); this is on the background of a very high TB incidence setting.104 The increased risk remains after the cessation of dust exposure. A study of former miners in Oklahoma aged over 50 years of whom a third had silicosis observed 8 (1.1%/year) of 367 people developed culture positive TB over a 2-year period.105 Despite improved working practices in many settings, there has not been a significant decrease in the number of miners with silicosis over the last 30 years, so silicosis as a risk for TB seems unlikely to disappear soon.106

Chemoprophylaxis has been shown to be effective in patients with LTBI and silicosis, but there are few high quality studies and the evidence base is weaker than that for many other risk groups such as HIV infected patients. A study using INH monotherapy showed a 93% reduction in active TB cases compared to placebo, but the study included people with other risk factors such as recent skin test convertors, close contacts of TB patients, and people with fibrotic lung lesions all of which have previously been shown to independently benefit from chemoprophylaxis.107 Another study from Hong Kong where many people are exposed to silica via the construction industry randomized a group of 625 patients with LTBI. Patients received 24 weeks of 300 mg INH daily, 12 weeks of 300 mg INH with 600 mg RIF daily, 600 mg RIF daily, or placebo daily for 24 weeks of therapy, all self-directed. After 5 years of follow-up, a 50% reduction in TB was seen; TB occurred in 13% of the chemoprophylaxis groups compared to 27% of the placebo group. There was no difference in efficacy between the different chemoprophylaxis groups.108

Diabetes mellitus

Diabetes mellitus (DM) is becoming more prevalent across the world. The 2017 International Diabetes Federation Atlas reports that there are 425 million people worldwide with DM, half of whom are undiagnosed; a further 325 million people are at risk of developing type 2 DM. Eighty percent of people with DM live in low or middle income countries; the same countries that have the highest incidence of TB. Although the prevalence of DM is predicted to rise across the world, the biggest increases over the next 3 decades are likely to be in the poorest and most populous regions, e.g., Africa, 156% predicted increase, and South East Asia, 84% predicted increase. In view of this, any interaction between the two epidemics of DM and TB could have important adverse consequences.109 The overall prevalence of diabetes among incident TB patients varies across countries but has been estimated to be between 1.9% and 45% with a median prevalence of 16%.110

DM has been associated with an increased risk of active TB in a number of studies. This risk varies between studies. A recent systematic review and meta-analyses that included studies with a total of over 58 million subjects including over 89,000 TB cases and involving 16 countries found that the measure of association between DM and TB varied from a relative risk or hazard ratio of 3.59 (95% CI 2.25–5.73) for prospective studies to a relative

risk (RR) or hazard ratio of 1.55 (95% CI 1.39–1.72) for retrospective studies. Overall when all the studies were combined, despite varying methodology, the measure of association was 2 (95% CI 1.78–2.24).111

The biological mechanism that predisposes people with DM to develop active TB is not well defined. There does appear to be an association with poorly controlled DM as well as competing factors such as excessive use of alcohol and smoking. It has been shown that people with poorly controlled DM and hyperglycemia have reduced intracellular killing of bacteria by leucocytes.112 Also, type 2 DM patients have been shown to have reduced interferon gamma production in response to stimuli; this could affect a person’s ability to control early TB infection, predisposing them to developing active disease.113 The association between hyperglycemia and TB has been observed in a cohort of African people, but the overall additional contribution of hyperglycemia to TB prevalence was felt to be small, and it is likely that the effect of DM will be less significant when other competing risk factors such as HIV infection are dominant in the population under study.114,115

One of the biggest risk factors for type 2 DM is obesity. Obesity has been shown to have a protective effect with regard to developing active TB. There is a complex interplay of risks between DM, obesity, and TB that may not cancel each other out. A large cohort study based in Taiwan involving 167,392 patients followed for a median of 7 years found individuals with a body mass index (BMI) >30 kg/m2 had a 67% (95% CI −3% to −90%) and 64% (95% CI 31%–81%) reduction in risk of developing TB in two cohorts. Overall, obesity appeared to have a protective effect with regard to developing TB that was canceled out in people who were both obese and had DM, compared to people who were neither obese nor had DM.116

Although the risk of active TB is clearly increased by DM, the relationship between TB infection and DM is less clear. A recent systematic review that included over 38,000 individuals found inconsistent associations between different study methodologies and designs. Overall there was a small but statistically significant association between DM and an increased risk of LTBI with a pooled odds ratio of 1.18 (95% CI 1.06–1.3).117 Screening patients with DM for LTBI in low TB incidence countries is not currently recommended in WHO guidelines unless other risk factors are present, but this may change as more evidence becomes available and prevalence of other risk factors changes.6,8

Chronic renal failure, dialysis

Chronic renal disease was recognized as a risk factor for the development of active TB over 40 years ago. The risk varies between studies and depends to some extent on the background of patients and coexisting conditions.(118–121) A large study from Australia found the incidence of TB in dialysis patients was 66.8/100,000 per year compared to 5.7/100,000 per year in the population as a whole. This gave an adjusted RR for people on dialysis of 7.8 (95% CI 3.3–18.7).122 A study from London, UK, showed a much higher TB prevalence; the cumulative TB incidence was 1,267/100,000 (95% CI 630–1904) in hemodialysis patients, 398/100,000 (95% CI, 80–1160) in peritoneal dialysis patients and 522/100,000 (95% CI 137–909) in renal transplant patients. These rates are 85, 26,

and 35 times greater than the background rate of TB in the UK.123 Active TB can be difficult to diagnose in patients with renal disease and may be more likely to be extrapulmonary and often peritoneal, especially in peritoneal dialysis patients. In view of being difficult to diagnose, screening and treatment of latent TB in this patient group is of particular importance.124

The choice of screening test for latent TB in patients with renal disease is important, TSTs are not sensitive due to energy with advanced renal disease, therefore IGRA tests are preferred.125,126

Chemoprophylaxis is recommended for patients with chronic kidney disease by NICE and CDC guidelines, also for patients receiving dialysis. WHO, NICE, and CDC recommend screening and treatment of LTBI.4–6 INH is removed to some extent by dialysis so should be given after completion of a hemodialysis session. Patients with renal failure are more liable to develop peripheral neuropathy so pyridoxine should be given with INH. RIF may reduce the level of immunosuppressant drugs given to patients with renal transplants, such as tacrolimus, so these drug levels should be carefully monitored if RIF is coadministered.127

Malignancy

Malignancy, especially head and neck cancer and hematological malignancy, are associated with reactivation of LTBI. A strong association with head and neck cancer compared to other malignancies was noted many years ago; the reason for this is multifactorial and may be related to weight loss, immunosuppression, chemotherapy, and radiotherapy.128

The largest recent study of the additional risk of TB reactivation posed by malignancy was based on a study of the Danish national medical databases. The study looked at 290,944 patients with cancer. The overall adjusted hazard ratio for TB among cancer patients was 2.48 (95% CI 1.99–3.1). The cancers with the three highest risks of TB reactivation were those of the aerodigestive tract, tobaccorelated cancer, and hematological malignancies. High risk was also noted to occur in the first year after cancer diagnosis, but remained elevated 5 years after diagnosis. Patients receiving chemotherapy or radiotherapy had an adjusted hazard ratio of 6.78 compared to the background rate.129 It therefore seems sensible to offer latent TB testing and treatment for patients with these types of malignancies and those due to undergo cytotoxic or radiotherapy.

Guidelines for testing and treating patients with malignancy for LTBI vary. In the UK, NICE 2016 recommends testing for LTBI and treating patients with hematological malignancies and patients receiving chemotherapy for other malignancies.4 In the United States, CDC guidelines recommend treatment for patients with head and neck cancer. Toxicity of LTBI treatment and interactions with chemotherapy agents should be taken into account, e.g., peripheral neuropathy caused by both INH and some cytotoxic drugs may be alleviated by pyridoxine. RIF may render some agents less effective by increasing their metabolism, such as corticosteroids.

Rapid weight loss and malnutrition

Active TB is associated with weight loss which, if treatment is delayed, can be marked. Rapid significant weight loss as a risk factor for developing active TB has been described.130,131 Weight loss

of more than 10% of ideal weight is probably an independent risk factor for developing active TB and is an indication for treatment of LTBI. In these cases the cause of weight loss may also be an additional risk factor such as malnutrition, malabsorption, gastrectomy, malignancy, intestinal bypass surgery, or starvation. Low BMI has also been recognized as a risk factor for developing TB disease, a relationship between BMI and the risk of developing TB has been shown in several cohorts.132

Being underweight and having a low BMI does not appear to be linked to a higher likelihood of having LTBI, as recent careful systematic review has shown.133

The effect of malnutrition on the success of LTBI treatment is not well defined but may be lowered due to a less effective immune system; medication used to treat LTBI has been reported to be more toxic in malnourished patients.134,135

Chronic peptic ulcer disease, postgastrectomy

Reactivation of latent TB and increased susceptibility to TB following subtotal gastrectomy has long been recognized.136 Gastrectomy for the treatment of gastric cancer has been associated with an increased risk of TB compared to the general population in the Republic of Korea, which has a current TB incidence of 39/100,000.137 A retrospective study of 1776 individuals who had undergone gastrectomy found 0.9% (16/1776) patients developed active TB, which equates to an annual incidence of 223.7 cases per 100,000. Other risk factors identified included previous TB and low BMI, possibly demonstrating the interplay between different risk factors.137 Interestingly, treatment of active TB in postgastrectomy patients has been associated with higher treatment failure rates; in one small case–control study 26% of patients had clinical treatment failure at 4 months.138,139

Intestinal bypass surgery

Surgery for morbid obesity, especially jejunoileal bypass surgery, has been shown to be very effective, leading to significant weight loss. It has also been associated with an increased risk of TB. The increased risk has been reported to be between 27 and 63 that of the general population.140,141 Laparoscopic weight loss techniques such as gastric banding do not seem to confer the same risk of TB compared to older surgical techniques, although there are case reports of TB after these procedures.142 This reduced risk may be because laparoscopic techniques cause less profound weight loss.

Smoking

A link between cigarette smoke and TB was first postulated as early as 1918 by G. B. Webb based on observations of TB rates in American soldiers who smoked.143 There have been many observational studies looking at the additional risk that smoking adds to the chance of a person becoming infected with TB and going on to develop active TB. Many of these studies have been confounded by other risk factors and behaviors that may put people at higher risk of TB such as homelessness, alcohol misuse, intravenous drug use, poverty, malnutrition, and other lung diseases. This makes it difficult to clearly

define the additional risk for TB due to smoking alone. Some of these factors may also affect the results of TB IGRA tests, making the situation even more complicated. A systematic review and meta-analyses by Jayes et al. summarized four cohort studies published since 2000 looking at the increased risk of active TB; three of the studies were graded as high quality. The summary estimate for the relative RR attributed to active smoking was 1.57 (95% CI 1.18–2.10); increasing risk was seen with increased number of cigarettes smoked. Other reviews have broken the risk down between three outcomes, TB infection, TB disease, and TB mortality. The evidence is strongest for TB disease with a relative risk of around 2.2. For TB infection, the evidence is less strong but the relative risk is around 1.5. For TB mortality, the relative risk is around 2.0.144–149 Generally, smoking is not identified in guidelines as a risk factor justifying treatment of LTBI unless associated with other risks.

The risk of TB in relation to secondhand or passive tobacco smoke is less clear cut. In a recent systematic review that assessed 12 studies there did not appear to be an increased risk of acquiring TB infection related to secondhand smoke exposure (RR 1.19, 95% CI 0.9–1.57), but there did appear to be an increased risk of developing TB disease (RR 1.59, 95% CI 1.11–2.27). The authors noted that the studies reviewed had quite marked heterogeneity so the overall risk in different setting remains unclear and more evidence is required.150

Low-risk individuals

Individuals at low risk of having latent TB and at low risk of developing active TB are not usually screened for LTBI unless they are entering a high risk setting for acquiring disease, or are vulnerable to active TB, such as patients starting aTNF treatment. Another low risk group of people who may be screened for LTBI are those entering occupations where the development of active TB would be potentially deleterious to those around them, such as health-care workers. In these cases, the benefit of treatment probably outweighs the risk of toxicity secondary to treatment. For other low risk individuals, the decision is more finely balanced, but online evidence-based decision tools exist that can help clinicians and individuals make decisions around treatment benefits and risks. One such calculator is the online TST/IGRA interpreter maintained by McGill University, Canada.151,152 Using this calculator, for example, an 18-year-old white person from the United States found to have a positive IGRA and TST>15 mm but with no recent TB contact and no other risk factors may have a lifetime risk of active TB of around 6% but a risk of hepatotoxicity secondary to INH close to 0. In contrast, a 65-year- old white person from the United States with no recent TB contact and no risk factors, with the same screening results, has a risk of 1.5% of developing active TB before the age of 80, but a risk of hepatotoxicity secondary to INH is around 5%. In general, young low risk individuals probably will benefit from chemoprophylaxis, but screening should follow local and national guidelines.153

MONITORING CHEMOPROPHYLAXIS

Individuals being treated for LTBI, as they do not have active disease, must be carefully monitored for adverse effects of medication

to minimize risks of harm. All patients should be counseled in terms and language that they can understand about what side effects to look out for and what action to take if they develop them, namely nausea, vomiting, itching rash, jaundice, and painful feet. Clinical evaluation on a monthly basis enquiring about gastrointestinal disturbance, rash, peripheral neuropathy, and jaundice should be undertaken.

Baseline liver enzymes are usually measured prior to starting LTBI treatment, even though there is not a strong evidence base to support this. Some authorities do not recommend measuring liver enzymes in all patients but just those at higher risk of hepatotoxicity such as patients with hepatitis B and C, HIV infection, heavy alcohol users, patients on hepatoxic medication, over 35 years of age, pregnant patients, and those in the postpartum period up to 90 days. A careful risk–benefit analysis should be undertaken before treating patients for latent TB with advanced liver disease, such as Child Pugh grade 3 and above, as the risks of life-threaten- ing hepatotoxicity are high. Patients with raised baseline alanine transaminase (ALT) or AST should be closely monitored with repeat liver enzyme tests after 2 weeks, then monthly. With this in mind it is good practice to measure liver enzymes on all patients prior to starting LTBI treatment and, where possible, blood-borne virus screening should be done.154

Hepatotoxicity secondary to LTBI treatment defined as a rise in ALT of greater than 3 times the upper limit of normal with symptoms or greater than 5 times the upper limit of normal without symptoms necessitates stopping treatment. The frequency of occurrence varies between regimens and individuals based on preexisting risk. RIF monotherapy is rarely associated with drug-induced hepatitis but may cause a rise in bilirubin.154 INH has been associated with fatal hepatotoxicity.11,14,15 A study from a public health clinic in the United States, which looked at 3377 patients treated with INH for latent TB found hepatotoxicity, defined as a rise in AST to greater than 5 times the upper limit of normal, occurred at a rate of 5.6 per 1000 patients; the number of hepatotoxic events per 1000 patients after 1, 3, and 6 months were 2.5, 7.2, and 4.1, respectively. There was also a strong association between hepatotoxicity and age with events occurring at a rate of 4.4 per 1000 patients in those aged 25–34 years compared to 20.8 per 1000 patients in those aged over 50 years.155,156 RPT/INH weekly treatment has been shown to be associated with a lower rate of hepatotoxicity compared to daily INH for 9 months. A study of 6862 participants found hepatotoxicity developed in 1.8% of patients receiving 9 months of INH compared to 0.4% of those receiving 3 months of RPT/INH. One of the risk factors identified for hepatotoxicity was hepatitis C infection, strengthening the argument for screening all latent TB patients for hepatitis prior to starting treatment, as well as closely monitoring these patients.34

COMPLETION OF TREATMENT

Completion of LTBI treatment is based not only on the duration of therapy but also on the total number of drug doses taken. For the 9-month INH monotherapy, the patient should receive at least 240 of the prescribed 270 doses of treatment within a year of starting therapy. For the 6-month INH regimen, 180 doses should be taken

within 9 months of starting therapy. For the 3-month regimen of INH and RIF, 90 doses should be taken within 4 months and for the 4-month regimen of RIF monotherapy, 120 doses should be taken within 3 months. These regimens are usually self-directed so are more difficult to monitor other than by pill count. The weekly regimen of RPT/INH consists of 12 doses and successful therapy is defined as at least 11 doses of medication taken within 16 weeks of starting therapy.34,37 If longer gaps in therapy than those given previously occur or if less than 75% of the prescribed doses are taken then retreatment should be considered after excluding the possibility of active TB. Supportive interventions such as dosette boxes, weekly key worker contacts, directly observed therapy, or video observed therapy should be considered for high risk individuals.157 A review into completion of latent TB treatment looking at 54 studies found one of the main barriers to completing treatment was length of treatment, which would favor the use of shorter, especially intermittent, regimens such as RPT/INH, Also culturally specific case management was found to improve adherence, which is important to consider in services covering a diverse population group.158 It should also be remembered that there is a high rate of drop out all the way through the care pathway of patients being screened and treated for LTBI, with a large proportion of patients not completing screening or starting treatment.24

RETREATMENT AND EXOGENOUS

REINFECTION

There is not a body of evidence to support the retreatment of people who have been treated for LTBI or active TB who go on to develop a medical condition that puts them at risk of TB reactivation. Several scenarios bear consideration though. Firstly, if a person has previously been treated for active TB prior to the introduction of RIF or if the person’s treatment for active TB was not completed, then LTBI treatment may be considered. Secondly, a person who has been reexposed to TB via, for example, a household contact, may benefit from repeat LTBI treatment. The contribution of exogenous reinfection with TB versus reactivation of latent disease even after previous treatment has become more clear with the widespread advent of typing. In the low TB incidence countries like United States and Italy, about 15%–23% of late recurrent TB cases are due to exogenous reinfection, respectively. This figure rises to 60% in certain groups such as recent immigrants who may be frequently reexposed to TB. In China, a high burden TB country, over 60% of recurrent TB cases have been shown to be due to exogenous reinfection.159–161

Lastly, people with fibrotic chest radiograph changes who have been previously treated for active or LTBI should be monitored closely if they undergo immunosuppressive treatment.

CONTACTS OF DRUG-RESISTANT

TB CASES

There is sparse evidence on the correct approach to take with regard to chemoprophylaxis of LTBI in people exposed to drugresistant TB (DRTB). Often the drug sensitivity of the index case

is not known in which case use of standard chemoprophylaxis is indicated even for patients with LTBI from high DRTB incidence countries. For mono-resistant TB it seems logical to use the agent that the index case is sensitive to, so 4 months of daily RIF can be used for contacts of an INH mono-resistant index case and 6–9 months of INH monotherapy can be used for contact with RIF mono-resistant index cases. The situation is more difficult for contacts of multidrug-resistant index cases.

There are estimated to be around 490,000 cases of multidrugresistant TB (MDRTB) in the world in 2016, with around 190,000 deaths.59 These MDRTB cases may generate upwards of 3 million cases of latent MDRTB.162 The need for effective chemoprophylaxis is great as MDRTB is much more difficult to treat, needs longer treatment, and uses more toxic, less well-tolerated agents than drug-sensitive TB. Outcomes are also poor compared to drugsensitive TB, so the potential gain from preventing MDRTB on an individual as well as population level is potentially greater than that of drug-sensitive TB.

There is lack of consensus on how to manage people with latent MDRTB infection. Some guidelines recommend close monitoring for 24 months, others advise individualized chemoprophylaxis.163,164 Both approaches will be discussed in the following section. Currently, there is a lack of good quality randomized trials on the effectiveness of chemoprophylaxis in these cases, but three trials are underway that may provide a useful guide. The three trials started recruiting in 2015 and will report hopefully by 2020. TB CHAMP (child multidrug-resistant preventive therapy) is being conducted in South Africa on children under 5 years. It is looking at levofloxacin versus placebo for 6 months and will follow patients for 18 months. PHOENix (Protecting Households On Exposure to Newly Diagnosed Index) is a multicenter trial recruiting adults and children looking at delamanid versus INH for 6 months with 22 months of follow-up and Levofloxacin versus placebo for the treatment of latent tuberculosis among contacts of patients with multidrug-resistant tuberculosis (V-QUIN MDRTB). The trial is recruiting adults and children in Vietnam, looking at 6 months of levofloxacin versus placebo with 30 months of follow-up.

Until these trials report there are two possible strategies for patients with possible latent MDRTB. Firstly, close observation for 24 months as recommended by WHO.6 This strategy involves identifying and registering contacts of MDRTB cases and performing clinical follow-up for at least 2 years, the period of highest risk of developing active TB. This strategy is far from passive and involves much effort to keep the patients involved, engaged, and not lost to follow-up. Early detection of active TB in these patients should allow the institution of appropriate therapy at an early stage of disease before significant lung damage has occurred, and could reduce the risk to others by allowing the patient to be isolated and rendered noninfectious.165

The second strategy involves giving targeted chemoprophylaxis based on the sensitivity of the index case isolate or based on the epidemiology of isolates in the area concerned. A study from the Federated States of Micronesia looked at 119 contacts of MDRTB patients. All were offered chemoprophylaxis. One hundred and four patients initiated chemoprophylaxis with daily flu- oroquinolone-based regimens for 12 months either alone or with

ethambutol or ethionamide depending on the index case sensitivity; 15 participants refused to take treatment. No cases of MDRTB were detected in the 104 patients given treatment compared to 3/15 cases in those who refused treatment. No serious adverse effects were reported.166 In a South African study of children who were contacts of ofloxacin-sensitive MDRTB patients, ofloxacin, ethambutol, and high dose INH for 6 months were given to 186 children regardless of skin test results, including HIV infected children. 3.2% of children developed TB, which is lower than the rates in historical controls. 3.7% of children developed a serious adverse effect and one child died.167 This compares to the observation from the same setting of 29/125 (29%) of MDRTB exposed but untreated children who went on to develop active MDRTB during a 30-month follow-up period.168

The overall quality of evidence in favor of treating contacts of MDRTB patients with chemoprophylaxis remains poor but a fluoroquinolone and ethambutol combination appears promising if the index case is sensitive. Current guidelines are therefore mainly based on expert opinion. A recent systematic review and metaanalyses reported that of the studies assessed, there was a 90% (9%–99%) reduction in MDRTB incidence among those receiving chemoprophylaxis; fluoroquinolone/ethambutol regimens had the greatest cost-effectiveness.169 Until clinical trial evidence is available, decisions around chemoprophylaxis should be based on local guidelines and conducted by centers experienced in the management of MDRTB.

PREGNANCY AND LACTATION

INH and RIF are safe for women to take during pregnancy, but women diagnosed with LTBI while pregnant can be treated after delivery. In some high risk cases such as women with advanced HIV infection, treatment of LTBI during pregnancy may be considered, but with the advent of highly effective ART, which is usually given during pregnancy, the risk of these women developing TB has been reduced, allowing LTBI treatment to be deferred.

An evaluation of pregnancies that occurred during two large trials of 12 weekly doses of INH/RPT and 9 months of INH alone for the treatment of latent TB found no excess of fetal abnormalities or fetal loss in either treatment group among 126 pregnancies that occurred during treatment or follow-up, including 87 pregnancies where the mother was exposed to the study drugs, compared to the background rate for the United States.170

There is some evidence that women are more likely to develop active TB during the first 180 days postpartum period, so starting LTBI treatment postpartum maybe particularly effective. There is some suggestion that hepatotoxicity due to INH is more likely in the puerperal period, so liver enzyme monitoring is suggested.171,172

Breastfeeding is safe while taking LTBI treatment. INH is found in breast milk at concentrations 20% of that in plasma. This probably does not pose a risk to a breastfeeding infant, although some authorities recommend giving pyridoxine to premature or low weight breastfed infants in these cases.

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