David P. Holland

Costs and Cost-effectiveness of Four Treatment Regimens for Latent Tuberculosis Infection

RATIONALE Isoniazid given daily for 9 months is the standard treatment for latent tuberculosis infection (LTBI), but its effectiveness is limited by poor completion rates. Shorter course regimens and regimens using directly observed therapy result in improved adherence but have higher upfront costs. OBJECTIVES To evaluate the costs and cost-effectiveness of regimens for the treatment of LTBI. METHODS We used a computerized Markov model to estimate total societal costs and benefits associated with four regimens for the treatment of LTBI: self-administered isoniazid daily for 9 months, directly observed isoniazid twice-weekly for 9 months, directly observed isoniazid plus rifapentine once weekly for 3 months, and self-administered rifampin daily for 4 months. In the base-case analysis, subjects were assumed to have newly positive tuberculin skin tests after recent exposure to infectious tuberculosis. MEASUREMENTS AND MAIN RESULTS We determined the costs of treatment, quality-adjusted life-years gained, and cases of active tuberculosis prevented. In the base-case analysis, rifampin dominated (less costly with increased benefits) all other regimens except isoniazid plus rifapentine, which was more effective at a cost

Intracranial tuberculomas developing while on therapy for pulmonary tuberculosis

48,997 per quality-adjusted life year gained. Isoniazid plus rifapentine dominated all regimens at a relative risk of disease 5.2 times the baseline estimate, or with completion rates less than 34% for isoniazid or 37% for rifampin. Rifampin could be 17% less efficacious than self-administered isoniazid and still be cost-saving compared with this regimen. CONCLUSIONS In our model, rifampin is cost-saving compared with the standard therapy of self-administered isoniazid. Isoniazid plus rifapentine is cost-saving for extremely high-risk patients and is cost-effective for lower-risk patients.

Cost-effectiveness of a 12-dose regimen for treating latent tuberculous infection in the United States.

We describe the case of a south Asian man who developed symptomatic intracranial tuberculomas while on therapy for pulmonary tuberculosis. The development or progression of intracranial tuberculomas during the course of appropriate antituberculous therapy has been recognised previously. We review the epidemiology, pathophysiology, diagnosis, and treatment of this paradoxical phenomenon. Although the aetiology of this reaction is unknown, it may be related to an enhanced immune response during the course of therapy. Routine brain imaging for all patients diagnosed with tuberculosis is not recommended; however, in patients presenting with new neurological findings, neuroimaging is clearly warranted. Stereotactic brain biopsy should be done whenever the diagnosis of an intracranial tuberculoma is in doubt. When intracranial tuberculomas become symptomatic, antituberculous therapy generally does not need to be changed. Corticosteroids are indicated in all symptomatic cases.

Therapeutic Drug Monitoring of Antimycobacterial Drugs in Patients with Both Tuberculosis and Advanced Human Immunodeficiency Virus Infection

SETTING A large randomized controlled trial recently showed that for treating latent tuberculous infection (LTBI) in persons at high risk of progression to tuberculosis (TB) disease, a 12-dose regimen of weekly rifapentine plus isoniazid (3HP) administered as directly observed treatment (DOT) can be as effective as 9 months of daily self-administered isoniazid (9H). OBJECTIVES To assess the cost-effectiveness of 3HP compared to 9H. DESIGN A computational model was designed to simulate individuals with LTBI treated with 9H or 3HP. Costs and health outcomes were estimated to determine the incremental costs per active TB case prevented and per quality-adjusted life year (QALY) gained by 3HP compared to 9H. RESULTS Over a 20-year period, treatment of LTBI with 3HP rather than 9H resulted in 5.2 fewer cases of TB and 25 fewer lost QALYs per 1000 individuals treated. From the health system and societal perspectives, 3HP would cost respectively US

Geographic Information System-based Screening for TB, HIV, and Syphilis (GIS-THIS): A Cross-Sectional Study

21,525 and

Strategies for treating latent multiple-drug resistant tuberculosis: a decision analysis.

4294 more per TB case prevented, and respectively

Potential Economic Viability of Two Proposed Rifapentine-Based Regimens for Treatment of Latent Tuberculosis Infection

4565 and

Self-administered versus directly observed once-weekly isoniazid and rifapentine treatment of latent tuberculosis infection

911 more per QALY gained. CONCLUSIONS 3HP may be a cost-effective alternative to 9H, particularly if the cost of rifapentine decreases, the effectiveness of 3HP can be maintained without DOT, and 3HP treatment is limited to those with a high risk of progression to TB disease.

Current management options for latent tuberculosis: A review

Study Objective. To determine the feasibility of therapeutic drug monitoring for adjusting low serum antimycobacterial concentrations in patients with both tuberculosis and advanced human immunodeficiency virus (HIV).

Diagnosis of pelvic tuberculosis in a patient with tubal infertility.

Objective To determine the feasibility and case detection rate of a geographic information systems (GIS)-based integrated community screening strategy for tuberculosis, syphilis, and human immunodeficiency virus (HIV). Design Prospective cross-sectional study of all participants presenting to geographic hot spot screenings in Wake County, North Carolina. Methods The residences of tuberculosis, HIV, and syphilis cases incident between 1/1/05–12/31/07 were mapped. Areas with high densities of all 3 diseases were designated “hot spots.” Combined screening for tuberculosis, HIV, and syphilis were conducted at the hot spots; participants with positive tests were referred to the health department. Results and Conclusions Participants (N = 247) reported high-risk characteristics: 67% previously incarcerated, 40% had lived in a homeless shelter, and 29% had a history of crack cocaine use. However, 34% reported never having been tested for HIV, and 41% did not recall prior tuberculin skin testing. Screening identified 3% (8/240) of participants with HIV infection, 1% (3/239) with untreated syphilis, and 15% (36/234) with latent tuberculosis infection. Of the eight persons with HIV, one was newly diagnosed and co-infected with latent tuberculosis; he was treated for latent TB and linked to an HIV provider. Two other HIV-positive persons had fallen out of care, and as a result of the study were linked back into HIV clinics. Of 27 persons with latent tuberculosis offered therapy, nine initiated and three completed treatment. GIS-based screening can effectively penetrate populations with high disease burden and poor healthcare access. Linkage to care remains challenging and will require creative interventions to impact morbidity.