Tuberculosis in the intensive care unit: alternative treatment regimens and association with mortality

Abstract

objectives Adequate anti-tuberculosis (TB) treatment is an important factor that can affect the patient's outcome. Higher mortality is found in patients who do not receive optimal treatment that includes isoniazid and rifampicin. The objective of this study is to evaluate the association of use of alternative TB treatment regimens (without rifampicin and isoniazid) and mortality among patients requiring intensive care. methods Retrospective cohort study, from January 2010 to December 2018. Patients aged > 18 years with a TB diagnosis, admitted to the ICU of a general, tertiary care, university-affiliated hospital (Hospital de Cl ınicas de Porto Alegre-HCPA) were included. Data on TB treatment used and outcomes of treatment were collected. results 462 patients met the inclusion criteria and were included in the analysis; 284 used the usual treatment regimen (rifampicin, isoniazid, pyrazinamide and ethambutolall orally), and 178 used alternative treatment regimens (IV levofloxacin plus oral ethambutol plus IM streptomycin or IV amikacin, without rifampicin and isoniazid). The mortality was higher among users of alternative treatment regimens (63.5%) than among usual treatment regimen users (51.4%) (P = 0.011). In a multivariate analysis, age, albumin and death were independently associated with alternative treatment regimens use. conclusions TB programmes in which IV rifampicin is not widely available should consider including it, especially for critically ill TB patients, for whom there may be improved survival.

Population study on diagnosis, treatment and outcomes of critically ill patients with tuberculosis (2008–2018)

“…Furthermore, there is inconsistent access to intravenous rifampicin and isoniazid in Hong Kong. Inability to give first-line treatment may be a contributing factor to excess mortality 23. Furthermore, our DAG-guided multivariable model showed that the RR of 1.68 (95% CI 1.18 to 2.40) was a direct estimation of the effect of second-line drugs on hospital mortality (table 3 and online supplemental figure 1).…”

Diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients: A mini review for clinicians

“…Most available ATTs are available in peroral formulations, making administration difficult in critically ill patients who often require endotracheal intubation and with multiorgan failure. Hypoalbuminaemia is one of the most common laboratory findings in TB patients in the intensive care unit and is an associated risk factor for a higher mortality[ 49 ]. Hypoalbuminaemia can contribute to gut oedema, impairing enteral absorption leading to low serum concentrations of ATTs, as well as impair the volume of distribution of ATTs by altering the drug binding of albumin-bound rifampicin and ethambutol[ 30 , 50 ].…”

Tuberculosis in Spain: An opinion paper

“…The characteristics of the critically ill patient, the route of administration, drug absorption, bio-availability, dose modification in case of hepatic and renal dys-function, and interaction with other drugs should be considered to ensure adequate plasma levels. Conventional regimens (rifampicin, isoniazid, pyrazinamide and oral ethambutol) have been shown to reduce mortality compared to alternative regimens (IV levofloxacin plus oral ethambutol plus IM streptomycin or IV amikacin, without rifampicin or isoniazid) [ 122 ]. Suboptimal concentrations of some drugs lead to recommend the intravenous use of specific treatments that are not always available in all countries.…”