Background While low body mass index (BMI) is associated with poor tuberculosis (TB) treatment outcomes, the impact of weight gain during TB treatment is unclear. To address this knowledge gap, we assessed whether a lack of weight gain is associated with all-cause mortality during and after TB treatment. Methods We conducted a retrospective cohort study among adults with newly diagnosed multidrug or extensively drug-resistant (MDR/XDR) pulmonary TB in Georgia between 2009-2020. The exposure was a change in BMI during the first 3-6 months of TB treatment. All-cause mortality during and after TB treatment was assessed using the National Death Registry. We used competing-risk Cox proportional hazard models to estimate adjusted hazard ratios (aHRs) between BMI change and all-cause mortality. Results Among 720 adult participants, 21% had low BMI (<18.5 kg m-2) at treatment initiation and 9% died either during (n=16) or after treatment (n=50). During the first 3-6 months of TB treatment, 17% lost weight and 14% had no weight change. Among 479 adults with normal baseline BMI (>= 18.5-<25 kg m-2), weight loss was associated with an increased risk of death during TB treatment (aHR 5.25, 95% CI 1.31-21.10). Among 149 adults with a low baseline BMI, no change in BMI was associated with increased post-TB treatment mortality (aHR 4.99, 95% CI 1.25-19.94). Conclusions Weight loss during TB treatment (among those with normal baseline BMI) or no weight gain (among those with low baseline BMI) was associated with increased rates of all-cause mortality. Our findings suggest that scaling up weight management interventions among those with M/XDR TB may be beneficial.

Background:While low body mass index (BMI) is associated with poor tuberculosis (TB) treatment outcomes, the impact of weight gain during TB treatment is unclear. To address this knowledge gap, we assessed if lack of weight gain is associated with all-cause mortality during and after TB treatment. Methods:We conducted a retrospective cohort study among adults with newly diagnosed multi- or extensively drug-resistant (M/XDR) pulmonary TB in Georgia between 2009-2020. The exposure was a change in BMI during the first 3-6 months of TB treatment. All-cause mortality during and after TB treatment was assessed using the National Death Registry. We used competing-risk Cox proportional hazard models to estimate adjusted hazard ratios (aHR) between BMI change and all-cause mortality. Results:Among 720 adult participants, 21% had low BMI (<18.5 kg/m2) at treatment initiation and 9% died either during (n=16) or after treatment (n=50). During the first 3-6 months of TB treatment, 17% lost weight and 14% had no weight change. Among 479 adults with normal baseline BMI ( ≥18.5-24.9 kg/m2), weight loss was associated with an increased risk of death during TB treatment (aHR=5.25; 95%CI: 1.31-21.10). Among 149 adults with a low baseline BMI, no change in BMI was associated with increased post-TB treatment mortality (aHR=4.99; 95%CI: 1.25-19.94). Conclusions:Weight loss during TB treatment (among those with normal baseline BMI) or no weight gain (among those with low baseline BMI) was associated with increased rates of all-cause mortality. Our findings suggest that scaling up weight management interventions among those with M/XDR TB may be beneficial.

In this large-scale, population-based cohort study we found that both treated and untreated hepatitis C are associated with active tuberculosis (TB). People with hepatitis C should be considered for TB-preventive measures, such as treatment for latent TB infection. Background Hepatitis C virus (HCV) infection causes dysregulation and suppression of immune pathways involved in the control of tuberculosis (TB) infection. However, data on the role of chronic hepatitis C as a risk factor for active TB are lacking. We sought to evaluate the association between HCV infection and the development of active TB. Methods We conducted a cohort study in Georgia among adults tested for HCV antibodies (January 2015-September 2020) and followed longitudinally for the development of newly diagnosed active TB. Data were obtained from the Georgian national programs of hepatitis C and TB. The exposures of interest were untreated and treated HCV infection. A Cox proportional hazards model was used to calculate adjusted hazard ratios (aHRs). Results A total of 1 828 808 adults were included (median follow-up time: 26 months; IQR: 13-39 months). Active TB was diagnosed in 3163 (0.17%) individuals after a median of 6 months follow-up (IQR: 1-18 months). The incidence rate per 100 000 person-years was 296 among persons with untreated HCV infection, 109 among those with treated HCV infection, and 65 among HCV-negative persons. In multivariable analysis, both untreated (aHR = 2.9; 95% CI: 2.4-3.4) and treated (aHR = 1.6; 95% CI: 1.4-2.0) HCV infections were associated with a higher hazard of active TB, compared with HCV-negative persons. Conclusions Adults with HCV infection, particularly untreated individuals, were at higher risk of developing active TB disease. Screening for latent TB infection and active TB disease should be part of clinical evaluation of people with HCV infection, especially in high-TB-burden areas.

High-throughput centralized testing for tuberculosis (TB) and drug resistance is important, but comparative data are limited. In this retrospective cross-sectional study, participants were recruited from Johannesburg, South Africa, and Tbilisi, Georgia. The index tests, Abbott RealTime MTB (RT-MTB) and RealTime MTB RIF/INH (RT-MTB RIF/INH), were performed on specimens stored frozen for an extended period of time (beyond manufacturer-validated specifications) and compared to paired Xpert MTB/RIF Ultra (Xpert Ultra) and Xpert MTB/RIF (Xpert) results obtained with fresh specimens. The detection reference standard was the Mycobacterium tuberculosis complex culture, and for resistance detection, it was phenotypic drug susceptibility testing. The median age of 474 participants was 39 (interquartile range [IQR], 31 to 51) years. On decontaminated sputum, Xpert Ultra had a sensitivity of 91%, compared to 77% for RT-MTB, with a difference of +14% (95% confidence interval [CI], +9.2 to +21%; 18/127). On raw sputum, Xpert Ultra exhibited a sensitivity of 89% and Xpert one of 88%, compared to 80% for RT-MTB, exhibiting differences of +10% (95% CI, +3.3 to +18%; 9/93) and +8.6% (95% CI, +2.4 to +17%; 8/93), respectively. Specificity was ≥98% for all tests. All three tests showed high sensitivity and specificity for detection of rifampin resistance. Abbott assays may have lower sensitivity than Xpert and Xpert Ultra for TB detection but similar performance for detection of resistance. The differences in TB detection may be attributable to differences in testing of frozen (Abbott) versus fresh (Xpert) samples. Studies in compliance with manufacturer's instructions are required to compare performance. IMPORTANCE In 2019, 10 million people fell ill with tuberculosis (TB), of whom 1.4 million died. There are few comparative studies of diagnostic assays, particularly those aiming to be used in high-throughput laboratories. One such assay is the Abbott RealTime MTB (RT-MTB) and RealTime MTB RIF/INH (RT-MTB RIF/INH), which uses the m2000 platform already in use in many settings for HIV load testing and allows the diagnosis of TB and resistance to two first-line drugs, rifampin and isoniazid. Our study compared the RT-MTB and RT-MTB RIF/INH to the WHO-recommended Xpert MTB/RIF Ultra and Xpert MTB/RIF. The study is the largest comparative study to date and was performed independent of the manufacturer. The study results suggest that the Abbott RealTime MTB may have a lower sensitivity, but the study may have placed the Abbott test at a disadvantage by using frozen samples and comparing the results to those for fresh samples for the Xpert.

Introduction: Adherence to second-line antituberculosis drug is challenging. A combination of strategies needs to be implemented to achieve adherence. In Georgia an optimized adherence support (OAS) – a package of education, psychosocial support and adherence counselling – was added to the already existing package of adherence support (supervised treatment, adherence incentives, transport cost reimbursement) to improve adherence and increase treatment success. We assessed the additive benefits of OAS on adherence and treatment outcomes. Methodology: This was a before and after cohort study using routine programme data in the National Center for Tuberculosis and Lung Diseases in Tbilisi. All adult rifampicin- and multidrug-resistant tuberculosis (RR/MDR-TB) patients enrolled for treatment under directly observed therapy in the NCTLD during the period before (June 2015 – January 2016) and after (June 2017 – January 2018) were included in the study. Primary outcomes were: i) adequate adherence defined as ≥ 85% of days covered by TB medication during the whole treatment period; ii) final treatment outcomes. Results: Of 221 RR/MDR-TB, most patients were male (76%, N = 167) with a mean age of 41 ± 14 years. Adherence data was available for 111 patients in the ‘before’ and 97 patients in the ‘after’ cohort. Adequate adherence was achieved by 62% (69/111) in the ‘before’ and 70% (68/97) in the ‘after’ cohort (p = 0.290). Overall treatment success was 64% (73/114) and 63% (67/107) in the ‘before’ and ‘after’ cohorts respectively (p = 0.937). Conclusions: Implementation of OAS had modest effect on adherence and had no additive benefits on treatment outcomes among RR/MDR-TB patients on 18-20 months regimen.

This study aimed to determine the health-related quality of life (HRQoL) of patients with pulmonary tuberculosis (TB) and to assess its change after a therapeutic surgical procedure. In this scenario, the purpose was to elucidate and quantify the effect of various demographic, epidemiological, clinical, surgical and psychosocial details on this variable. A prospective cohort of 40 patients undergoing therapeutic surgery for pulmonary TB (Study of Human Tuberculosis Lesions (SH-TBL) cohort) was recruited in Tbilisi, Georgia, between 2016 and 2018. HRQoL was assessed by administering the St George's Respiratory Questionnaire (SGRQ) and a novel psychosocial questionnaire, the BCN-Q, both at baseline and at 6 months post-surgery. A statistically and clinically significant improvement in the SGRQ total score was observed at follow-up, although it did not reach the values found for the healthy population. The differences between time points were statistically significant for the following groups: women, age <40 years, body mass index ≥20 kg·m−2, nonsmokers, drug-susceptible and drug-resistant participants, both new and relapsed patients, early culture negativisation, cases with a single lesion, either lesions <35 mm or ≥35 mm, and lesion, lobe and lung resections. The analysis of BCN-Q together with the SGRQ showed that several of its items, such as marital status, living conditions, nutrition, employment, external support, certain attitudes towards the healthcare system, emotional burden and sleep troubles, can impact HRQoL. These results highlight the benefit of adjuvant therapeutic surgery for pulmonary TB in selected patients in terms of HRQoL and suggest that a comprehensive approach including demographic, epidemiological, clinical and psychosocial variables may more accurately predict TB evolution and prognosis.

Trabajo presentado en Applied Bioinformatics and Public Health Microbiology Cambridge, UK, 5-7 June 2019

Background: Georgia has countrywide drug susceptibility testing (DST) coverage, but it has never been determined what proportion of drug-resistant tuberculosis (DR-TB) patients receive treatment in compliance with the DST profile and whether this compliance is associated with the treatment outcome. Objective: The aim of the study was to determine the extent of treatment adjustment and its association with treatment outcomes among DR-TB patients in Georgia. Methods: A retrospective cohort study was conducted among 670 DR-TB patients aged 18 years and older, from the 2015 and 2016 cohorts. Results: The initially prescribed treatment regimens of 319 (47.6%) DR-TB cases required adjustment. Of these, in 137 (42.9%) cases the regimen was completely adjusted and in 182 (57.0%) cases it was not completely adjusted: in 33 (33/182) cases the regimen was only partially adjusted and in 149 (149/182) cases it was not adjusted at all. Analysis shows that complete adjustment of treatment is significantly associated with successful treatment outcomes. Conclusion: For successful outcomes, all DR-TB treatment regimens, including resistant drug(s), should be adjusted based on the DST profile, regardless of the type of resistance, the number or type of resistant drug(s), and new or repurposed drugs being included in the regimen.

OBJECTIVES:Our aim was to retrospectively compare clinical data and characteristics of removed lesions of the cohort of patients undergoing therapeutical surgery for their tuberculosis.DESIGN AND METHODS:Demographic and epidemiological details, clinical data, data on the surgery performed, macroscopic characteristics of the TB lesions removed, and outcome were recorded retrospectively from the 137 patients who underwent therapeutical surgery for their TB in Tbilisi, Georgia during 2014 and 2015.RESULTS:Men represented 70% of the included patients, presented more comorbidities and underwent operation earlier in terms of days between diagnostic and surgery. Women underwent operation at younger ages, and in MDR/XDR-TB cases, showed higher percentages of sputum conversion at >2 months and of fresh necrosis in the surgical specimens, suggesting a worse evolution. Half of cases were MDR/XDR-TB cases. In spite of being considered microbiologically cured according to WHO, a non despricable percentage of cases showed viable bacilli in the surgical specimen. Even if no causality could be statistically demonstrated, differences could be encountered according to gender and drug susceptibility of the responsible strains.CONCLUSIONS:According to our results, host factors such as gender, type of necrosis found in the lesions, size of lesions and presence of viable bacilli in the surgical specimen, should be included in future studies on therapeutical surgery of TB. As most of studies are done in MDR/XDR-TB, more data on DS-TB operated cases are needed. Our results also highlight that, in spite of achieving the microbiologically cured status, sterilization might not occur, and thus new biomarkers and new methods to evaluate the healing process of TB patients are urgently needed and radiological assays should be taken into account.

BACKGROUNDTuberculosis, including multidrug-resistant tuberculosis (MDR-TB), is a major global health problem. Individuals with tuberculosis disease commonly exhibit vitamin D deficiency, which may adversely affect immunity and the response to therapy.OBJECTIVEWe determined whether adjunctive high-dose vitamin D3 supplementation improves outcomes in individuals with pulmonary tuberculosis disease.DESIGNThe study was a double-blind, randomized, placebo-controlled, intent-to-treat trial in 199 individuals with pulmonary tuberculosis disease in Tbilisi, Georgia. Subjects were randomly assigned to receive oral vitamin D3 [50,000 IUs (1.25 mg) thrice weekly for 8 wk and 50,000 IU every other week for 8 wk] or a placebo concomitant with standard first-line antituberculosis drugs. The primary outcome was the time for the conversion of a Mycobacterium tuberculosis (Mtb) sputum culture to negative.RESULTSBaseline characteristics between groups were similar. Most subjects (74%) were vitamin D deficient (plasma 25-hydroxyvitamin D [25(OH)D] concentration <50 nmol/L). With vitamin D3, plasma 25(OH)D concentrations peaked at ∼250 nmol/L by 8 wk and decreased to ∼125 nmol/L at week 16. Adverse events and plasma calcium concentrations were similar between groups. In 192 subjects with culture-confirmed tuberculosis, an adjusted efficacy analysis showed similar median culture-conversion times between vitamin D3 and placebo groups [29 and 27 d, respectively; HR: 0.86; 95% CI: 0.63, 1.18; P = 0.33). Eight-week culture-conversion rates were also similar (84.0% and 82.1% for vitamin D3 and placebo, respectively; P = 0.99).CONCLUSIONA high-dose vitamin D3 regimen safely corrected vitamin D deficiency but did not improve the rate of sputum Mtb clearance over 16 wk in this pulmonary tuberculosis cohort. This trial was registered at clinicaltrials.gov at NCT00918086.

The current clinical management of TB is complicated by the lack of suitable diagnostic tests that can be employed in infrastructure and resource poor regions. The mannose-capped form of lipoarabinomannan (ManLAM) is unique to the surface envelope of slow-growing, pathogenic mycobacteria such as M.tuberculosis (M.tb) and facilitates passive invasion of mononuclear phagocytes. The detection of this virulence factor in urine, sputum and serum has engendered interest in its employment as a biomarker for M.tb infection. In this study, we utilize a subtractive screening methodology to engineer the first high affinity recombinant antibody (My2F12) with exquisite specificity for the α1-2 mannose linkages enriched in ManLAM from M.tb. My2F12 binds to pathogenic mycobacterial species but not fast growing non-pathogenic species. Testing on matched urine and serum samples from TB patients indicates that My2F12 works in patient cohorts missed by other diagnostic methodologies.

Background: Malnutrition and lean tissue wasting are common in patients with tuberculosis (TB) disease, yet little information is available on habitual dietary intake or links with body composition.Methods: Dietary intake was obtained in a randomized clinical trial of high‐dose vitamin D (Vit D) in patients with pulmonary TB in Tbilisi, Georgia. Food intake was obtained (0, 8 and 16 weeks) using a validated, culture‐specific tool. Serial body composition was by BMI and bioelectrical impedance analysis (BIA; % fat mass and % fat‐free mass). Descriptive statistics and repeated measures ANOVA were used.Results: 192 subjects (mean age 35 y; 100 Vit D, 99 placebo) were studied. Mean daily intake of kcal, fat and protein were adequate at diagnosis and increased (with BMI) over time (time effect p<0.0001, treatment effect NS). There were no differences in % of fat mass or % fat‐free mass between groups over time. Multi‐drug resistant TB patients (n=23) had lower body weight, BMI (p=0.05) and fat‐free mass vs. drug‐susceptible patients, despite increased intake of kcal, protein, fat and CHO at 8 and 16 weeks.Conclusions: Macronutrient intake was adequate in this TB patient cohort. Increased macronutrient intake occurred concomitant with increased BMI and maintained proportions of body fat and fat‐free mass. MDR‐TB patients demonstrated less efficient anabolism than drug‐susceptible TB patients. 1Grant Funding Source: Supported by grants from the National Institutes of Health Fogarty grant D43 TW007124 and K24 RR0233

Background: We tested whether high‐dose oral cholecalciferol (VD3) enhances efficacy of anti‐TB drugs in pulmonary TB infection. Methods: Double blind, randomized, controlled, intent‐to‐treat trial in adults with pulmonary TB in Tbilisi, Georgia. A total of 199 subjects were randomized to VD3 (1,400,000 IU; n=100) or placebo (n=99) over 16 weeks + standard anti‐TB drugs. Sputum TB cultures were obtained at weeks 0, 2, 4, 6, 8, 12 and 16. Cox analysis was used for the primary outcome (time to culture conversion). Results: Of 784 subjects screened, 100 received VD3 and 99 placebo. Most subjects (> 85%) were VD deficient at entry (serum 25OH VD level < 20 ng/mL). 23 subjects (12%) had multidrug‐resistant TB (MDR‐TB) (12 vitamin D, 11 placebo). Entry demographic factors were similar between groups. VD3 was safe, with similar blood calcium levels and adverse events between groups. With VD, serum 25OH VD levels peaked at ≍ 100 ng/mL at 8 weeks and decreased to ≍ 60 ng/mL by week 16. Culture conversion was similar between groups at 8 weeks and over time [HR=0.84 (0.62‐1.15)]. However, the MDR‐TB subset showed enhanced culture conversion with VD3 therapy vs. placebo at 8 weeks (40 vs. 88%) and over time (each p<0.04). Conclusions: High‐dose VD3 was safe and did not improve TB clearance in the overall cohort of TB patients. However, clinical efficacy in patients with MDR‐TB suggests that VD treatment trials focus on this subset of patients.Grant Funding Source: Supported by NIH/NIDDK K24 DK096574 and Emory Global Health Institute

Background: Characterization of metabolites altered by tuberculosis (TB) disease may identify pathophysiologic pathways. Resolvins are lipid mediators derived from endogenous EPA and DHA critical for resolution of inflammation.Methods: Plasma samples from 17 patients (35±12 yrs old) with new pulmonary TB and 17 matched household contacts without TB (controls) were analyzed using high‐resolution LC‐MS. False discovery rate (FDR; q=0.05) and hierarchal cluster analysis was used to distinguish accurate mass ions (metabolites) significantly different between groups. The METLIN Metabolite Database was used to match ions to known metabolites. Identification of specific D‐series resolvins (RvD1 and RvD2) was confirmed by LC‐UV‐MS/MS.Results: Over 23,000 metabolites were detected in untargeted metabolomic analysis, of which 61 were significantly different between the two groups by FDR. Eight metabolite clusters were evident containing several metabolites quantitatively upregulated in patients with TB (e.g. glutamate, choline derivatives, anti‐TB drug metabolites and several lipids, including likely M. tb cell wall lipids and resolvins RvD1 and RvD2.Conclusions: This pilot study revealed metabolites that are upregulated during newly diagnosed TB potentially involved in pathogenesis. Upregulation of specific resolvins may mediate recovery from inflammation in TB disease.Grant Funding Source: Supported by grants from the National Institutes of Health Fogarty grants D43 TW007124

We aimed to characterize metabolites during tuberculosis (TB) disease and identify new pathophysiologic pathways involved in infection as well as biomarkers of TB onset, progression and resolution. Such data may inform development of new anti-tuberculosis drugs. Plasma samples from adults with newly diagnosed pulmonary TB disease and their matched, asymptomatic, sputum culture-negative household contacts were analyzed using liquid chromatography high-resolution mass spectrometry (LC-MS) to identify metabolites. Statistical and bioinformatics methods were used to select accurate mass/charge (m/z) ions that were significantly different between the two groups at a false discovery rate (FDR) of q<0.05. Two-way hierarchical cluster analysis (HCA) was used to identify clusters of ions contributing to separation of cases and controls, and metabolomics databases were used to match these ions to known metabolites. Identity of specific D-series resolvins, glutamate and Mycobacterium tuberculosis (Mtb)-derived trehalose-6-mycolate was confirmed using LC-MS/MS analysis. Over 23,000 metabolites were detected in untargeted metabolomic analysis and 61 metabolites were significantly different between the two groups. HCA revealed 8 metabolite clusters containing metabolites largely upregulated in patients with TB disease, including anti-TB drugs, glutamate, choline derivatives, Mycobacterium tuberculosis-derived cell wall glycolipids (trehalose-6-mycolate and phosphatidylinositol) and pro-resolving lipid mediators of inflammation, known to stimulate resolution, efferocytosis and microbial killing. The resolvins were confirmed to be RvD1, aspirin-triggered RvD1, and RvD2. This study shows that high-resolution metabolomic analysis can differentiate patients with active TB disease from their asymptomatic household contacts. Specific metabolites upregulated in the plasma of patients with active TB disease, including Mtb-derived glycolipids and resolvins, have potential as biomarkers and may reveal pathways involved in TB disease pathogenesis and resolution.

Objective: Evaluate serial plasma retinol and tocopherol levels in adults with new pulmonary tuberculosis (TB) in Tbilisi, Georgia.Methods: 129 subjects with pulmonary TB disease were enrolled in a randomized, controlled trial of high‐dose vitamin D3 (D3) + anti‐TB drugs. Plasma retinol, α‐tocopherol, and γ‐tocopherol were measured by HPLC (baseline, wks 8 and 16). Household contacts of TB subjects were baseline controls. Descriptive statistics (mean ± SD) and repeated measures ANOVA were used.Results: TB subjects exhibited significantly lower baseline plasma retinol (33.3 ± 11.7 vs. 58.8 ± 17.7 µg/dL; p < 0.001) and γ‐tocopherol (33.6 ± 15.6 vs. 40.8 ± 15.5 µg/dL; p = 0.02) levels vs. controls; α‐tocopherol levels were similar. D3 administration did not affect nutrient levels over time. Pooled data in all TB subjects revealed an increase in retinol levels over time (baseline to wk 16, +22%; p < 0.001). Levels of γ‐tocopherol rose at wk 8 (+11%; p < 0.001) but declined to baseline by wk 16. In contrast, α‐tocopherol fell by 9% at wk 16 vs. baseline (p < 0.01). Subjects with a BMI < 18.5 (n = 19), exhibited lower α‐tocopherol levels at wk 16 vs. baseline and wk 8 values (p = .003).Conclusions: Plasma retinol and tocopherol levels were lower in subjects with TB disease vs. uninfected household contacts. During anti‐TB treatment, plasma retinol increased and α‐tocopherol decreased, particularly in the more malnourished patients.Grant Funding Source: Supported by NIH K24 DK096574 and Emory Global Health Institute