Six-month therapy for abdominal tuberculosis

Abstract

BackgroundTuberculosis (TB) of the gastrointestinal tract and any other organ within the abdominal cavity is abdominal TB, and most guidelines recommend the same six-month regimen used for pulmonary TB for people with this diagnosis. However, some physicians are concerned whether a six-month treatment regimen is long enough to prevent relapse of the disease, particularly in people with gastrointestinal TB, which may sometimes cause antituberculous drugs to be poorly absorbed. On the other hand, longer regimens are associated with poor adherence, which could increase relapse, contribute to drug resistance developing, and increase costs to patients and health providers.ObjectivesTo compare six-month versus longer drug regimens to treat people that have abdominal TB.Search methodsWe searched the following electronic databases up to 2 September 2016: the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase (accessed via OvidSP), LILACS, INDMED, and the South Asian Database of Controlled Clinical Trials. We searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for ongoing trials. We also checked article reference lists.Selection criteriaWe included randomized controlled trials (RCTs) that compared six-month regimens versus longer regimens that consisted of isoniazid, rifampicin, pyrazinamide, and ethambutol to treat adults and children that had abdominal TB. The primary outcomes were relapse, with a minimum of six-month follow-up after completion of antituberculous treatment (ATT), and clinical cure at the end of ATT.Data collection and analysisTwo review authors independently selected trials, extracted data, and assessed the risk of bias in the included trials. For analysis of dichotomous outcomes, we used risk ratios (RR) with 95% confidence intervals (CIs). Where appropriate, we pooled data from the included trials in meta-analyses. We assessed the quality of the evidence using the GRADE approach.Main resultsWe included three RCTs, with 328 participants, that compared six-month regimens with nine-month regimens to treat adults with intestinal and peritoneal TB. All trials were conducted in Asia, and excluded people with HIV, those with co-morbidities and those who had received ATT in the previous five years. Antituberculous regimens were based on isoniazid, rifampicin, pyrazinamide, and ethambutol, and these drugs were administered daily or thrice weekly under a directly observed therapy programme. The median duration of follow-up after completion of treatment was between 12 and 39 months.Relapse was uncommon, with two cases among 140 participants treated for six months, and no events among 129 participants treated for nine months. The small number of participants means we do not know whether or not there is a difference in risk of relapse between the two regimens (very low quality evidence). At the end of therapy, there was probably no difference in the proportion o...

Abdominal tuberculosis in children: A real‐world experience of 218 cases from an endemic region

“…Apart from including only adults, two of the three studies included only those with intestinal involvement, which may not be applicable to children where the majority has involvement of multiple abdominal sites. Moreover, the authors of the review have conceded that the quality of evidence regarding the relapse estimate is very low, which is a big concern . Hence, till some robust pediatric data are available, we plan to continue treatment for 9–12 months.…”

“…Even though a review of three randomised controlled trials comprising 328 adult participants found a 6-month regimen to be efficacious, we believe it cannot be extrapolated to children. 26 Apart from including only adults, two of the three studies included only those with intestinal involvement, which may not be applicable to children where the majority has involvement of multiple abdominal sites. Moreover, the authors of the review have conceded that the quality of evidence regarding the relapse estimate is very low, which is a big concern.…”

Abdominal Tuberculosis

“…Cochrane researchers examined the available evidence up to the September 2, 2016 and concluded that 6-month regimens are probably as good as 9-month regimens in terms of numbers of people cured but more studies are needed for making confident conclusions. 8 Drug toxicity is a point of concern which requires a close follow up. In this study, eight patients (10.5%) developed hepatotoxicity due to ATT, seven out of whom tolerated either sequential reinitiation of ATT or modified ATT.…”

Herausforderungen in der Diagnostik der Darmtuberkulose – Pitfalls einer vergessenen infektiösen Erkrankung: Eine Fallserie und Literaturübersicht

“…Zusammenfassend empfehlen die Autoren/innen eine 6-monatige Therapie wie bei einer pulmonalen Tuberkulose. Die ersten beiden Monate sollte eine vierfache Kombination, bestehend aus Isoniazid, Rifampicin, Pyrazinamid und Ethambutol, gegeben werden, gefolgt von viermonatiger Behandlung mit Isoniazid und Rifampicin [48]. Eine Gefahr stellen die weltweit ansteigenden Zahlen von resistenten Mykobakterien dar [1].…”