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Query: UMLS:C0019693 (HIV)
 170,526 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Failure to recognize Multidrug-Resistant Tuberculosis (MDR-TB) has been the cause of explosive outbreaks. To avoid this devastating consequence of the disease, especially among HIV-infected persons, critical care staff must use preventive strategies. This article provides information on the pathogenesis of MDR-TB, its epidemiology, and some case management problems associated with the disease. Also provided are checklists to identify the risk of infection and instructions on how to combat infection if it is diagnosed.
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PMID:Multidrug-resistant tuberculosis: a new era in prevention and control. 765 66

From 1988 to 1990, an outbreak of multidrug-resistant tuberculosis (MDR-TB) among patients, and an increased number of tuberculin-skin-test conversions among healthcare workers, occurred on the HIV ward of Jackson Memorial Hospital, Miami, Florida, USA. Measures similar to those subsequently recommended in the 1990 Centers for Disease Control and Prevention guidelines were implemented on the HIV ward by June, 1990, and in September, 1992, we evaluated the efficacy of these control measures. Among MDR-TB patients and healthcare workers with tuberculin-skin-test conversions on the HIV ward, we looked for evidence of exposure to HIV ward MDR-TB patients positive for acid-fast bacilli in sputum during initial (January-May, 1990) and follow-up (June, 1990-June, 1992) periods. Exposure before implementation of control measures to an infectious MDR-TB patient on the HIV ward was recorded in 12 of 15 (80%) MDR-TB patients during the initial period and 5 of 11 (45%) MDR-TB patients during follow-up. After implementation of control measures, no episodes of MDR-TB could be traced to contact with infectious MDR-TB patients on the HIV ward. Skin-test conversions among workers on the HIV ward declined from 7 of 25 (28%) during the initial period to 3 of 17 (18%) in the early (June, 1990-February, 1991) and 0 of 23 in the late (March, 1991-June, 1992) follow-up periods (p < 0.01). Skin-test conversions among healthcare workers were not associated with increased exposure to MDR-TB patients, and were not significantly higher among workers on the HIV ward than on a control ward without tuberculosis patients (3/27 vs 0/16). These data demonstrate that implementation of measures similar to the Centers for Disease Control and Prevention 1990 tuberculosis-control guidelines were effective in halting transmission of MDR-TB to healthcare workers and HIV-infected patients.
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PMID:Control of nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis among healthcare workers and HIV-infected patients. 782 19

Outbreaks of multidrug-resistant Mycobacterium tuberculosis (multidrug-resistant tuberculosis; MDR-TB) have recently been reported in hospitals in the United States. Rapid spread of these bacilli and a high mortality among immunocompromised patients, i.e. HIV-infected individuals and AIDS patients, were observed. Factors that play a role in these outbreaks and the prevention of MDR-TB are discussed in this article. Awareness of a possible M. tuberculosis infection and the early introduction of measures to reduce the spread of these micro-organisms are steps that can prevent a nosocomial outbreak. The use of more rapid methods for culturing mycobacteria and determining their sensitivity to antimicrobial drugs can accelerate the diagnostic process and the recognition of multiresistance. In view of the poor results of treatment of MDR-TB, prevention should be the first requirement.
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PMID:Prevention of nosocomial spread of multidrug-resistant tubercle bacilli. 805 47

The treatment and prevention of tuberculosis in HIV-infected patients present significant new challenges. In patients with drug-susceptible organisms, treatment initially with three- and four-drug followed by two-drug regimens used for 6 to 9 months is efficacious, although there appears to be higher rates of adverse drug reactions than in HIV-negative patients. Treatment of MDR-TB is more difficult, requiring a high index of clinical suspicion and rapid detection and the use of multiple drugs with lower efficacy and greater toxicity than first-line agents. Directly observed therapy is the single most effective public health strategy to ensure completion of therapy and to prevent the emergence of drug-resistant tuberculosis. Isoniazid preventive therapy should be given to HIV-infected patients who are tuberculin positive and considered in selected patients who are anergic. There are many unresolved issues and future needs, including (1) the optimal regimen and duration of therapy for drug-sensitive tuberculosis; (2) the necessity for maintenance therapy following completion of a multidrug regimen; (3) an optimal regimen for treatment of MDR-TB; (4) the duration of isoniazid preventive therapy; (5) efficacy and duration of other preventive regimens, for example, pyrazinamide and rifampin; (6) the need for and choice of drugs for persons exposed to MDR-TB; (7) development of new antimycobacterial agents; and (8) the feasibility of some of these strategies in developing countries, which have the greatest burden of tuberculosis with HIV infection. Ongoing and future studies will address these questions to ultimately improve the treatment and prevention of tuberculosis in the HIV-infected patient.
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PMID:Treatment and prevention of tuberculosis in HIV-infected persons. 808 67

The management of MDR-TB requires that the clinician become familiar with the "second-line" antimycobacterial agents. These drugs are generally less potent and frequently more toxic than isoniazid and rifampin. Because they are less active, innovative dosing schedules may allow us to take advantage of the few strengths that they possess. This approach will require further research into the dose-response relationships for each agent. Based on our current knowledge of these drugs, practical guidelines for their use have been described. These guidelines include the gradual escalation of the oral doses of PAS, cycloserine, and ethionamide over several days, and the intravenous administration of streptomycin and capreomycin. Both ciprofloxacin and ofloxacin may be used for the treatment of MDR-TB, but data from clinical trials are currently lacking. Finally, because patients with AIDS appear to develop antimycobacterial drug malabsorption over the course of their HIV infection, therapeutic drug monitoring can be used to verify drug absorption in the individual patient. This approach may improve therapy for that patient and prevent the selection of additional drug resistance.
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PMID:Pharmacology of the antimycobacterial drugs. 823 10

There has been a significant increase in the number of cases of MDR-TB in the United States. Although cases of MDR-TB have been reported from many areas of the country, the majority of the cases are concentrated in large urban areas. MDR-TB is difficult and expensive to treat. CDC has developed a National Action Plan to Combat Multidrug-Resistant Tuberculosis. The main elements of this plan include (1) greater surveillance and epidemiologic studies of drug-resistant TB; (2) initiatives to make the laboratory diagnosis of MDR-TB more rapid, sensitive, and reliable; (3) education of health care professionals about MDR-TB, its prevention, control, and treatment; and (4) measures to facilitate the development of new antituberculous drugs. CDC has published guidelines for the prevention of nosocomial spread of MDR-TB. to prevent the development and spread of MDR-TB, medical practitioners must suspect TB and make the diagnosis as rapidly as possible. Once a patient is diagnosed with TB, the most important step to prevent the development of drug-resistant disease is to ensure that patients take all of their medication. Directly observed therapy is the best way of ensuring this. In addition, more specific interventions, such as the use of incentives to improve compliance in certain situations, may need to be applied to groups in which high rates of drug resistance have been found, such as HIV-positive persons, IDUs, homeless persons, and persons who have been exposed to persons with MDR-TB. Quick and effective public health interventions targeted at these defined groups should help to control the spread of both drug-susceptible and drug-resistant TB.
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PMID:The epidemiology of multidrug-resistant tuberculosis in the United States. 823 19

Human immunodeficiency virus infection has profoundly affected the epidemiology, natural history, and clinical presentation of TB. It has also contributed in part to the recent epidemic of MDR-TB in the US and significantly reduced the sensitivity (but not the specificity) of the tuberculin skin test. Further research is needed to determine the optimal strategy for chemoprophylaxis in HIV-infected individuals, new methods of diagnosing TB infection and disease, and new drugs to control MDR-TB. Most importantly, however, further funding is necessary to improve compliance with therapy and chemoprophylaxis in order to regain control of this ancient scourge.
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PMID:Tuberculosis and HIV infection: epidemiology, pathogenesis, and clinical aspects. 825 Mar 47

We recently observed a striking increase in multidrug-resistant tuberculosis (MDR-TB) among patients admitted to the Chest Service at Bellevue Hospital Center in New York. We reviewed the laboratory susceptibility test results of 4,681 tuberculosis (TB) cases over the past 20 years, Combined resistance to isoniazid and rifampin increased from 2.5 percent in 1971 to 16 percent in 1991 with higher rates noted for individual drugs. We reviewed the medical records of 100 patients with drug-resistant TB, finding that these individuals were predominantly less than 40 years of age, minority, male, jobless, undomiciled, with a high percentage of drug abuse and human immunodeficiency virus infection. We conclude that the epidemics of AIDS and TB are complicated by a third epidemic of MDR-TB. This third epidemic requires urgent attention to achieve more rapid diagnosis, to develop new therapeutic regimens, and to address the social and hospital environment ot care for these individuals.
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PMID:The third epidemic--multidrug-resistant tuberculosis. 827 81

Beginning in 1985, the long decline in TB cases was dramatically reversed; from 1985 through 1992 reported cases increased 20.1 percent nationally. Two characteristics of this resurgent epidemic are unique: its prevalence among immunocompromised HIV-infected people and the emergence of multidrug-resistant TB. Current epidemiological trends, demographics and treatment approaches are discussed, as well as the implications MDR-TB holds for dentistry.
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PMID:MDR-TB. Another challenge from the microbial world. 829 63

We analyzed the clinical and laboratory findings and outcome of 173 patients hospitalized at our institution from 1983 to 1994 with multidrug-resistant tuberculosis (MDR-TB) and evaluated outcome. The 173 patients (mean age 40 +/- 1 yr) were predominantly male (92%), African American or Hispanic (80%), and mostly undomiciled. Over half (52%) were known to be HIV-infected. HIV-positive MDR-TB patients had significantly more pulmonary and constitutional symptoms, more extrapulmonary disease, and fewer cavitary lesions on chest radiographs. Fifty-five percent of the patients in the cohort have died; mortality was significantly greater for HIV-positive than HIV-negative (72% versus 20%, p < 0.01). The median duration of survival of MDR-TB patients was 22 +/- 1 mo. Overall, extrapulmonary involvement was a risk factor for shorter survival, while a cavitary lesion on initial chest film and institution of appropriate treatment were positive predictors of survival. In HIV+ patients, only appropriate therapy was associated with prolonged survival (median of 14.1 mo). Interestingly, there was a trend toward better outcome in the first half of the decade reviewed. We conclude that although mortality from MDR-TB is high in both HIV-positive and HIV-negative patients, institution of appropriate therapy is the factor most strongly associated with a favorable outcome. Development of new diagnostic and therapeutic strategies for MDR-TB are urgently needed.
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PMID:Outcome of MDR-TB patients, 1983-1993. Prolonged survival with appropriate therapy. 854 37


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