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This prospective study included 150 newly diagnosed pulmonary and extrapulmonary tuberculous children. The organism was isolated and identified after decontamination. Antimicrobial susceptibility testing was performed by proportion method using Lowenstein-Jensen medium (PMLJ) and Etest. Minimal inhibitory concentration for both first and second line anti tuberculous drugs was determined by Etest. Comparison between the two methods was done.
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Resistance-associated hot mutations could be determined within 2 h after PCR amplification using pyrosequencing. About 45 fg DNA per reaction was required to obtain sufficient PCR products to produce a clear, accurate pyrosequencing pattern. No mutations were found in all 20 drug-susceptible clinical isolates, while all isolates with mutations showed corresponding drug resistances.
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Altered pharmacokinetics of antituberculosis drugs may contribute to an increased risk of tuberculosis treatment failure for diabetic patients. We previously found that rifampin exposure was 2-fold lower in diabetic than in nondiabetic tuberculosis patients during the continuation phase of treatment. We now examined the influence of diabetes on the pharmacokinetics of antituberculosis drugs in the intensive phase of tuberculosis treatment, and we evaluated the effect of glycemic control. For this purpose, 18 diabetic and 18 gender- and body weight-matched nondiabetic tuberculosis patients were included in an Indonesian setting. Intensive pharmacokinetic sampling was performed for rifampin, pyrazinamide, and ethambutol at steady state. The bioavailability of rifampin was determined by comparing rifampin exposure after oral versus intravenous administration. Pharmacokinetic assessments were repeated for 10 diabetic tuberculosis patients after glycemic control. No differences in the areas under the concentration-time curves of the drugs in plasma from 0 to 24 h postdose (AUC(0-24)), the maximum concentrations of the drugs in plasma (C(max)), the times to C(max) (T(max)), and the half-lives of rifampin, pyrazinamide, and ethambutol were found between diabetic and nondiabetic tuberculosis patients in the intensive phase of tuberculosis treatment. For rifampin, oral bioavailability and metabolism were similar in diabetic and nondiabetic patients. The pharmacokinetic parameters of antituberculosis drugs were not correlated with blood glucose levels or glucose control. We conclude that diabetes does not alter the pharmacokinetics of antituberculosis drugs during the intensive phase of tuberculosis treatment. The reduced exposure to rifampin of diabetic patients in the continuation phase may be due to increased body weight and possible differences in hepatic induction. Further research is needed to determine the cause of increased tuberculosis treatment failure among diabetic patients.
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National Tuberculosis Programme, the Philippines.
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Tetrandrine is a natural chemical product purified from fourstamen stephania root which recently has been shown to act similarly as synthesized drug efflux pump inhibitor verapamil. The aim of the study is to examine whether tetrandrine could potentiate anti-tubercular drugs to which Mycobacterium tuberculosis (MTB) has turned resistant via efflux mechanisms.
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These pulmonary MAC cavities were significantly frequently located in segments S2, S3, S9, and S10, and their distribution was different from that of pulmonary tuberculosis at the patients' initial visit. Examination of the external diameters of these cavities after chemotherapy showed that 42.1% of cavities expanded, 0.2% were unchanged, and 56.1% shrank. The mean diameter of the cavities decreased significantly (by 3.1 mm) after chemotherapy. The mean size of the cavities in the upper lobe did not differ from the mean size of the cavities in the lower lobe before chemotherapy; however, the reduction in cavity size was significantly higher in the lower lobe cavities. In 14 cases, the cavities disappeared under the standard chemotherapy regimen in an average of 971 days, and there was a tendency for lower lobe cavities to disappear more rapidly.
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Ethambutol (EMB) is a first-line drug used for antitubercular therapy in combination with other drugs as recommended by World Health Organization DOTS/DOTS-Plus regimens. EMB is also effective in the treatment of opportunistic mycobacterial infections in patients with human immunodeficiency virus. The emb locus has been considered as a drug target for EMB, and substitutions of codon 306 in Mycobacterium tuberculosis gene embB have been shown to be the most frequent and predictive mutations for EMB resistance. The aim of the present study was to detect embB and embC gene mutations in EMB-resistant clinical isolates. A total of 23 isolates of M. tuberculosis from patients with pulmonary tuberculosis were included in the study. Drug sensitivity was tested by proportion method and E-test. All 23 isolates were EMB resistant. Primers to amplify the embB and embC gene were designed, and polymerase chain reaction products were subjected for sequence analysis. H37Rv standard laboratory strain was used as control. Nucleotide sequencing showed that 16 strains had a mutation in the embB gene. The most common mutation observed in the embB gene was at codon 306, followed by mutations at codons 299 and 378 in 4 and 2 isolates, respectively. Novel mutations have been reported at codons 239, 240, 247, 282, 311, 368, 397, 446, 469, and 471. Sequence analysis of the embC gene showed mutation in 8 isolates at codon 270. Novel mutations in embC have been reported at codons 251 and 254. The most common nucleotide polymorphism in our isolates was at codons 306 and 299 in the embB gene and at codon 270 in the embC gene. A mutation at codon 306 was usually associated with high-level ethambutol resistance.
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The MICs of isoniazid and ethambutol were equal or slightly above the critical concentration in most of the strains (92% and 84%, respectively), defined as "low-level resistance". Rifampicin and streptomycin exhibited very high MICs in most of the strains (100% and 77%, respectively), indicating a "high-level resistance".
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The specific management of drug-resistant patients is only possible where facilities exist for both mycobacterial culture and for drug-susceptibility testing. Treatment guidelines in the United Kingdom and elsewhere are predicated on the drug-resistance data prevailing in the circumstances of their use. In developed countries, the inclusion of the fourth drug (ethambutol but occasionally streptomycin) depends on the level of isoniazid resistance expected or known in a given patient group. Most parts of the world do not have the capabilities to perform mycobacterial culture and drug-susceptibility testing. In these countries, therefore, the "standard" advised regimen has to cover the possibility of the commoner drug resistances. The view taken in the United Kingdom is that where drug-susceptibility tests are available, they should be followed, and treatment modified. The drug treatment of multidrug-resistant tuberculosis (MDR TB), defined as combined resistance to rifampicin and isoniazid, plus or minus other antituberculosis drugs, is complex, time consuming, and demanding on both patient and physician. In the United Kingdom the advice is that treatment should only be carried out by physicians with substantial experience in managing complex resistant cases, only in hospitals with appropriate isolation facilities, and in very close liaison with Mycobacteriology Reference Centres. Treatment should start with five or more drugs to which the organism is, or is likely to be, susceptible and continued until sputum cultures become negative. Treatment with three drugs should continue for at least an additional nine months.