Clinical outcomes of new algorithm for diagnosis and treatment of Tuberculosis sepsis in HIV patients Kenneth Byashalira, Peter Mbelele, Hadija Semvua, Jaffu Chilongola, Seleman Semvua, Alphonce Liyoyo, Blandina Mmbaga, Sayoki Mfinanga, Christopher Moore, Scott Heysell, Stellah Mpagama International Journal of Mycobacteriology 2019 8(4):313-319 Background: Despite effort to diagnose tuberculosis (TB) in the Human Immunodeficiency Virus (HIV) infected population, 45% of adults with HIV that had a previously unknown reason for death, demonstrated TB was the cause by autopsy examination. We aimed to assess the clinical outcomes of implementation a new algorithm for diagnosis and treatment of tuberculosis (TB) related sepsis among PLHIV presenting with life-threatening illness. Methods: This study is a prospective cohort conducted in three-referral hospitals in Kilimanjaro, recruited 97 PLHIV from February through June 2018. Patients provided urine and sputum samples for testing lateral flow – lipoarabinomannan (LF-LAM) and Xpert Mycobacterium tuberculosis (MTB)/rifampicin (RIF) assays, respectively. Anti-TB was prescribed to patients with positive LF-LAM or Xpert MTB/RIF or received broad-spectrum antibiotics but deteriorated. Results: Of 97 patients, 84 (87%) provided urine and sputa, and 13 (13%) provided only urine. The mean age (95% confidence interval) was 40 (38–43) years and 52 (54%) were female. In 84 patients, LF-LAM increased TB detection from 26 (31%) by Xpert MTB/RIF to 41 (55%) by both tests. Of 97 patients, 69 (71%) prescribed anti-TB, 67% (46/69) and 33% (23/69) had definitive and probable TB respectively. Sixteen (16.5%) patients died, of which one died before treatment, 73% (11/15) died within 7 days of admission. The 30-day survival was similar in both treatment groups (log rank = 0.1574). Mortality was significantly higher among hospitalized patients compared to outpatients (P ≤ 0.027). Conclusion: Implementation of new algorithm increased TB case detection in patients that could have been missed by Xpert MTB/RIF assay. Survival of PLHIV with confirmed or probable TB was comparable to those of PLHIV that were treated with broad-spectrum antibiotics alone. Further work should focus on the optimal timing and content of the immediate antimicrobial regimen for sepsis among PLHIV in TB-endemic settings.

Diversified lineages and drug-resistance profiles of clinical isolates of Mycobacterium tuberculosis complex in Malaysia Mohd Nur Noorizhab Fakhruzzaman, Norzuliana Zainal Abidin, Zirwatul Adilah Aziz, Wai Feng Lim, Johari James Richard, Mohd Noordin Noorliza, Mat Hussin Hani, Rusli Norhayati, Abu Bakar Zamzurina, Md Yusof Farida Zuraina, Muhammad Jamari Hisyam, Lay Kek Teh, Mohd Nor Norazmi, Mohd Salleh Zaki International Journal of Mycobacteriology 2019 8(4):320-328 Background: Tuberculosis (TB) is still a major health problem in Malaysia with thousands of cases reported yearly. This is further burdened with the emergence of multidrug-resistant TB (MDR-TB). Whole-genome sequencing (WGS) provides high-resolution molecular epidemiological data for the accurate determination of Mycobacterium tuberculosis complex (MTBC) lineages and prediction of the drug-resistance patterns. This study aimed to investigate the diversity of MTBC in Malaysia in terms of lineage and drug-resistance patterns of the clinical MTBC isolates using WGS approach. Methods: The genomes of 24 MTBC isolated from sputum and pus samples were sequenced. The phenotypic drug susceptibility testing (DST) of the isolates was determined for ten anti-TB drugs. Bioinformatic analysis comprising genome assembly and annotation and single-nucleotide polymorphism (SNP) analysis in genes associated with resistance to the ten anti-TB drugs were done on each sequenced genome. Results: The draft assemblies covered an average of 97% of the expected genome size. Eleven isolates were aligned to the Indo-Oceanic lineage, eight were East-Asian lineage, three were East African-Indian lineage, and one was of Euro-American and Bovis lineages, respectively. Twelve of the 24 MTBC isolates were phenotypically MDR M. tuberculosis: one is polyresistance and another one is monoresistance. Twenty-six SNPs across nine genes associated with resistance toward ten anti-TB drugs were detected where some of the mutations were found in isolates that were previously reported as pan-susceptible using DST. A haplotype consisting of 65 variants was also found among the MTBC isolates with drug-resistance traits. Conclusions: This study is the first effort done in Malaysia to utilize 24 genomes of the local clinical MTBC isolates. The high-resolution molecular epidemiological data obtained provide valuable insights into the mechanistic and epidemiological qualities of TB within the vicinity of Southeast Asia.

Validation of bedaquiline drug-susceptibility testing by BACTEC MGIT 960 system for Mycobacterium tuberculosis Gomathi Sivaramakrishnan, Balaji Subramanyam, Michel Prem Kumar, Radhika Golla, Srikanth Prasad Tripathy, Rajesh Mondal International Journal of Mycobacteriology 2019 8(4):329-332 Background: Bedaquiline (BDQ) is a new antituberculosis (TB) drug effectively used for the treatment of multidrug-resistant and extensively drug-resistant TB. However, the reports on drug-susceptibility testing (DST) for BDQ are scarce. The study aimed to validate and standardize BDQ DST by BACTEC MGIT 960 system for Mycobacterium tuberculosis. Methods: A panel of ten M. tuberculosis isolates comprising 8 BDQ sensitive and 2 BDQ resistant strains were used to test accuracy, repeatability, and reproducibility of BDQDST by MGIT 960. BDQ DST by Middlebrook 7H11 agar method using polystyrene tubes was used as a standard method to calculate the accuracy of the validation. Results: DST by MGIT for BDQ showed 100% accuracy, repeatability, and reproducibility, although variations were observed in the growth units of the “test” MGIT tubes between technologist and drug stocks while testing for reproducibility. Conclusion: BDQ DST by MGIT 960 system is accurate, repeatable, and reproducible and hence can be implemented in certified laboratories routinely performing DST by MGIT 960 system.

Insights in tuberculosis immunology: Role of NKT and T regulatory cells Pooja Pandey, Anuj Kumar Bhatnagar, Anant Mohan, Kuldeep Singh Sachdeva, Madhu Vajpayee, Bimal Kumar Das, Jyotish Chandra Samantaray, Randeep Guleria, Urvashi Balbir Singh International Journal of Mycobacteriology 2019 8(4):333-340 Background: Tuberculosis (TB) control is challenging due to poor drug compliance and emerging resistance. The need of the hour is to determine the prediction of disease cure and relapse. Patients' immune response is crucial to the disease outcome. This study was designed to study the immune profile of TB patients during treatment and cure. Methods: The cross-sectional study included newly diagnosed pulmonary TB patients and healthy controls. Levels of serum cytokines/chemokines (Th1/Th2/Th17) were measured by BD cytometric bead array. The cell surface markers assessed in the study were CD3, CD4, CD8, CD16, CD56, and BD human regulatory T cell cocktail (CD4/CD25/CD127). Results: Data analysis observed statistically significant differences in CD3dim/CD56 + natural killer T (NKT) among TB patients with significantly low levels in healthy controls and after treatment completion (P < 0.0001). The analysis also revealed a high percentage of CD3dim/CD56 + NKT in fast responders. The percentage of T regulatory was found to be high in patients when compared with healthy controls; the values were statistically significant (0.0002). Interleukin-6 was significantly associated with the disease (P < 0.0485). Discussion: A comprehensive understanding of role of CD3dim/CD56+ NKT in antimycobacterial immunity may enable new possibilities for NK cell-based prophylactic and/or therapeutic strategies against TB.

Effectiveness of anti-tuberculosis chemotherapy in patients with tuberculosis relapse compared with newly diagnosed patients Dmytro Butov, Mykola Gumenuik, Galyna Gumeniuk, Anton Tkachenko, Vasyl Kikinchuk, Ruslan Stepaniuk, Alexandr Peshenko, Tetiana Butova International Journal of Mycobacteriology 2019 8(4):341-346 Background: To study the effectiveness of antituberculosis chemotherapy in patients with relapse pulmonary tuberculosis (RTB) compared with patients with the newly diagnosed process. Methods: We examined 285 TB patients, including 126 individuals with RTB (Group 1) and 159 patients with newly diagnosed pulmonary tuberculosis (NDPTB) (Group 2). All patients were diagnosed with infiltrative PTB. Effectiveness of the basic course of antimycobacterial treatment was assessed in accordance with the following data: time required for the normalization of clinical manifestations, smear conversion, cavity healing, disappearance of infiltrative and focal changes in the pulmonary tissue, as well as the final clinical effectiveness of therapy. Results: Disappearance of clinical symptoms was statistically significantly faster in Group 2 compared with RTB patients in 2.25 ± 0.11 and 3.40 ± 0.15 months, respectively (P < 0.001). Sputum culture conversion was observed after 6 months of treatment in 138 (86.79%) patients with NDPTB and 89 (72.22%) patients from Group 1 (P = 0.0023). Closure of cavities and disappearance of infiltrative and focal changes in the lungs occurred within 6 months of chemotherapy only in 55 (43.65%) patients with RTB and 93 (58.49%) patients with NDPTB (P = 0.0133). Conclusions: Standard treatment for patients with NDPTB is considered successful in case of faster health improvement and stabilization, less pronounced rates of toxic adverse reactions to antiTB drugs, faster sputum smear and culture conversion and cavity healing, signs of clinical and radiological convalescence, and the reduced number of large residual changes after the treatment compared with RTB.

Hospital admissions for tuberculous pericarditis in the United States 2002–2014 Neiberg de Alcantara Lima, Christopher Stancic, Duncan Vos, Mireya Mireya del Carmen Diaz Insua, Carol Cavalcante de Vasconcelos Lima, Ricardo Lessa de Castro, Rheanne Maravelas, Thomas A Melgar International Journal of Mycobacteriology 2019 8(4):347-350 Background: Extra pulmonary manifestations of tuberculosis (TB) are rare in developed countries. TB is the main etiology of chronic pericarditis in developing countries, but it's epidemiology is not unknown in the United States. Methods: This retrospective study used the Healthcare Utilization Projects/Nationwide Inpatient Sample (HCUPS/NIS) database from 2002-2014 to evaluate the characteristics, risk factors, trends over time and region of tuberculous pericarditis in the United States. Results: The data during the study period consists of 100,790,900 discharges accounting for 482,872,274 weighted discharges. The data showed 744 weighted discharges with indication of both tuberculosis and pericarditis. A co-ocurrence of TB pericarditis and malignancy or chronic kidney disease was more common than in patients without TB pericarditis. The frequency of co-ocurrence of TB pericarditis and HIV infection, obesity, alcohol abuse and organ transplant was not elevated. Conclusion: TB pericarditis is rare disease in the USA and the classical risk factors for lung tuberculosis may not be associated with TB pericarditis. CKD and malignancy appear to be associated with TB pericarditis, further studies are required to determine causality.

GeneXpert Mycobacterium tuberculosis/rifampicin assay for molecular epidemiology of rifampicin-Resistant Mycobacterium tuberculosis in an Urban Setting of Banten province, Indonesia Paulus Mario Christopher, Cucunawangsih , Allen Widysanto International Journal of Mycobacteriology 2019 8(4):351-358 Background: Tuberculosis (TB) is the fourth leading cause of death in Indonesia. In 2017, the World Health Organization (WHO) estimated that only 2% of the TB patients in Indonesia had only been tested with rapid diagnostics at the time of diagnosis, resulting in largely underdetected rifampicin-resistant TB (RR-TB). Utilization of GeneXpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) assay as a point-of-care molecular assay to detect TB and RR-TB and serving its purpose in accordance with the first pillar of the WHO End-TB Strategy. Objective: This study investigated the use of GeneXpert MTB/RIF assay to determine the molecular epidemiology of RR-TB in an urban setting of Indonesia. Methods: All molecular epidemiological and microbiological databases were retrospectively examined from GeneXpert MTB/RIF assay results in Siloam Hospital Lippo Village. The sociodemographic characteristics and results of microbiological examinations consisting of Ziehl–Neelsen staining and GeneXpert MTB/RIF assay were analyzed. Results: During the study period, 600 cases were registered, and GeneXpert MTB/RIF tests were done in which the tests yielded 597 (99.5%) valid results; 62.0% were male and adult of age category; of whom 29 samples (4.9%) were found to be RR-TB, 186 samples (31.2%) were RIF sensitive, and remainders were negative. Conclusions: The results of GeneXpert MTB/RIF to be a fundamental diagnosis of RR-TB and subsequently to notify MDR-TB were satisfying and valuable in this study. This further increased and reinforced TB surveillance and national TB program to finally bring about WHO end-TB strategy one step closer in Indonesia.

Determinants of treatment failure among tuberculosis patients in Kandahar City, Afghanistan: A 5-year retrospective cohort study Bilal Ahmad Rahimi, Najeebullah Rahimy, Mavuto Mukaka, Qudratullah Ahmadi, Mohammad Sami Hayat, Abdul Wahed Wasiq International Journal of Mycobacteriology 2019 8(4):359-365 Background: Tuberculosis (TB) is a preventable and treatable chronic disease. Afghanistan is among the high-TB-burden countries. The aim of this study is to find the determinants of treatment failure among TB patients in Kandahar City, Afghanistan. Methods: This was a retrospective cohort study conducted in Kandahar City during a period of 5 years (August 2014–July 2019). For data analysis; descriptive statistics, Chi-square test, and logistic regression were used. Results: Among 1416 TB patients, 894/1416 (63.1%) had pulmonary TB (PTB), whereas 522/1416 (36.9%) had extrapulmonary TB (EPTB). Mean age in these patients was 34.7 years while most of them were females in PTB (530/894 [59.3%]) and EPTB (340/522 [65.1%]) patients. Sputum smear was positive in 618/860 (71.9%) and 16/404 (4%) of PTB and EPTB patients, respectively. TB treatment failure was more in PTB (56/894 [6.3%]) than EPTB (4/522 [0.8%]). Chi-square test of TB cases showed that statistically significant determinants that may cause the treatment failure were re-treatment cases (crude odds ratio [COR] 7.7, P < 0.001), absence of fever (COR 5.2, P < 0.001), absence of cough (COR 1.7, P = 0.004), living in rural areas (COR 1.4, P = 0.035), and no weight loss (COR 1.3, P = 0.033). Binary logistic regression of the statistically significant variables revealed only absence of fever (adjusted odds ratio 6.0, P < 0.001) as the risk factor for treatment failure in TB patients. Conclusion: TB is still a major threat for Kandahar City. Low treatment success rate and increased number of defaulted cases are the major threats.

Country-wide rapid screening for the Mycobacterium tuberculosis Beijing sublineage in Ecuador using a single-nucleotide polymorphism-polymerase chain reaction method Carlos Mora-Pinargote, Daniel Garzon-Chavez, Greta Franco-Sotomayor, Margarita Leon-Benitez, Juan Carlos Granda-Pardo, Gabriel Trueba, Jacobus Henri de Waard, Miguel Angel Garcia-Bereguiain International Journal of Mycobacteriology 2019 8(4):366-370 Background: Strains of the Beijing sublineage of Mycobacterium tuberculosis have caused large outbreaks of tuberculosis, often involving multidrug resistance strains and this genetically highly conserved family of strains predominates in some geographic areas. For most of the countries of Latin America, no country-wide studies about the prevalence of the Beijing lineage are available. Methods: In this study, we determine the prevalence of the Beijing sublineage in Ecuador, using a large nation-wide sample of 991 isolates from the years 2014–2016 and with the strains, in case-related-proportional representation, emerging from most of the provinces of the country. The isolates were genotyped with asinglenucleotidespecific polymorphism (SNP) polymerase chain reaction for the Beijing sublineage. SNPpositive strains were confirmed as belonging to this lineage with 24 mycobacterial interspersed repetitive unitvariable number of tandem repeat and DNA sequencing. Results: We identified only four Beijing isolates in this collection of 991 strains and calculated a prevalence rate of 0.43%. Conclusions: Our study shows a limited dissemination of the Beijing strains in the Ecuadorian population. This in contrast with the neighbor countries of Peru and Colombia were locally a prevalence of up to 16% has been reported.

Newly registered tuberculosis: A comparison of rate and success of management in two island districts with different in accessibility of transportation in Thailand Sora Yasri, Viroj Wiwanitkit International Journal of Mycobacteriology 2019 8(4):371-373 Background: Tuberculosis is an important infection that can be seen in several countries. The occurrence of disease in the remoted setting is an interesting issue that is an actual challenge for management. Here, the authors present and discuss on the newly registered tuberculosis cases in two island districts of Thailand, a tropical endemic country in Southeast Asia. Methods: The authors hereby retrospectively analyzed registered data of newly registered tuberculosis cases in two island districts with different in accessibility of transportation in Thailand. A comparison of rate and success of management was made. Results: According to the statistical analysis, there is a significant difference of incidence rates of newly registered tuberculosis cases between the two island districts (0.13% vs. 0.04%). There is also a significant difference of successful antituberculosis drug management rates between the two island districts (72.7% vs. 100%). Conclusion: The island district with easier accessibility by transportation has a more number of newly registered tuberculosis case and a less success rate of antituberculosis drug treatment.