The challenge of managing extensively drug-resistant tuberculosis at a referral hospital in the state of São Paulo, Brazil: a report of three cases

Abstract

Here, we report the cases of three patients diagnosed with extensively drug-resistant tuberculosis and admitted to a referral hospital in the state of São Paulo, Brazil, showing the clinical and radiological evolution, as well as laboratory test results, over a one-year period. Treatment was based on the World Health Organization guidelines, with the inclusion of a new proposal for the use of a combination of antituberculosis drugs (imipenem and linezolid). In the cases studied, we show the challenge of creating an acceptable, effective treatment regimen including drugs that are more toxic, are more expensive, and are administered for longer periods. We also show that treatment costs are significantly higher for such patients, which could have an impact on health care systems, even after hospital discharge. We highlight the fact that in extreme cases, such as those reported here, hospitalization at a referral center seems to be the most effective strategy for providing appropriate treatment and increasing the chance of cure. In conclusion, health professionals and governments must make every effort to prevent cases of multidrug-resistant and extensively drug-resistant tuberculosis.

Comparison of effectiveness and safety of imipenem/clavulanate-versusmeropenem/clavulanate-containing regimens in the treatment of MDR- and XDR-TB

“…The prevalent sex of the cohort was male (105, 58.3%) and the median (IQR) age was 35 (26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45) years (table 1).…”

“…New drugs, such as delamanid, [12][13][14] and bedaquiline [15][16][17][18][19][20], and a few repurposed drugs ( presently included in WHO Group 5, i.e. drugs with unknown/limited evidence on efficacy and/or tolerability) are presently attracting scientific interest [7,21], among them linezolid [10,[22][23][24][25][26][27][28] and carbapenems [29][30][31][32][33][34]. The carbapenem group of drugs, which includes meropenem, imipenem and ertapenem, are currently used to treat MDR-and XDR-TB cases, although the evidence available on their efficacy, safety and tolerability is extremely limited [29][30][31][32][33][34].…”

“…Evidence on imipenem/clavulanate is even more limited, consisting of a series of 10 patients and one case report [33,34].…”

Effectiveness and safety of meropenem/clavulanate-containing regimens in the treatment of MDR- and XDR-TB

“…drugs with unknown/limited evidence on efficacy and/or tolerability [7,21]. This group includes linezolid [10,[22][23][24][25][26][27][28] and carbapenems [29][30][31][32][33][34]. Carbapenems represent an interesting class of drugs (including meropenem, imipenem and ertapenem), which are widely used to treat MDR-and XDR-TB cases, although very limited evidence exists regarding their efficacy, safety and tolerability [29][30][31][32][33][34].…”

Série Histórica da Tuberculose Resistente a Múltiplos Medicamentos (TB-MR) no Estado do Pará, Brasil, 2005- 2010.

“…dificulta o cálculo de futuros gastos, tanto para o paciente quanto para os cofres públicos, o que caracteriza a TB-MR como uma doença de gastos incalculáveis. 13,14 Para tal, os estudos voltados para a análise da evolução da doença a partir da análise social, epidemiológica e clínica da patologia são de extrema importância, por permitir o uso destes dados como ferramenta para o combate e controle eficazes da TB-MR. 15 Com a finalidade de contribuir para a construção de conhecimento acerca da doença, este artigo traz os resultados da pesquisa cujo objetivo foi o de avaliar a evolução histórica da TB-MR no estado do Pará nos anos de 2005 a 2014.…”