Fluoroquinolones in Multidrug-Resistant Tuberculosis - ATS Journals

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Wilkinson and colleagues (1) have published the first prospective study demonstrating the importance of early treatment on out- comes of chronic obstructive ...
Correspondence Exacerbations of Chronic Obstructive Pulmonary Disease: Should Self-Management Be Used? To the Editor:

Wilkinson and colleagues (1) have published the first prospective study demonstrating the importance of early treatment on outcomes of chronic obstructive pulmonary disease (COPD) exacerbations. They defined an exacerbation as the presence for at least two consecutive days of an increase in any two major symptoms (dyspnea, sputum purulence, sputum amount) or increase in one major and one minor symptom (wheeze, sore throat, cough, symptoms of a common cold). Patients who received prompt treatment after the onset of an exacerbation were likely to recover more rapidly than those who delayed reporting their exacerbation and thus began treatment later. Patients who habitually failed to seek therapy for their exacerbations had poorer quality of life and were more likely to be hospitalized for management of an exacerbation. The authors point out the need for improved symptom recognition and earlier reporting of exacerbations by patients. They suggest patient education, methods of improving compliance, and self-management plans as suitable subjects for investigation. The literature on self-management of COPD is controversial. Monninkhof and colleagues (2) did a 1-year randomized, controlled trial (RCT) on 248 patients with COPD, and Hermiz and colleagues (3) reported an RCT on 177 patients with COPD. Both of these studies failed to show positive effects of a selfmanagement program. Bourbeau and coworkers (4) performed an RCT on the effects of self-management in patients with moderate to severe COPD; they showed reduction in use of health care services and improved health status. Gallefoss (5), in an RCT on 62 patients with mild and moderate COPD, showed improved patient outcomes and reduced costs in a 12-month follow-up. The definition of an exacerbation used by Wilkinson and colleagues (1) required symptoms to be present for at least two consecutive days. It is reasonable to ask whether with self-management, treatment could start earlier, say after 24 hours of symptoms. Additional research is needed to establish, in practice, the best way of starting treatment earlier for exacerbations of COPD. It would also be useful to determine whether self-management has a place in this schema. Conflict of Interest Statement : G.L.S. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

Gordon L. Snider Boston University School of Medicine Boston, Massachusetts References 1. Wilkinson TM, Donaldson GC, Hurst JR, Seemungal TA, Wedzicha JA. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2004;169:1298–1303. 2. Monninkhof E, van der Valk P, van der Palen J, van Herwaarden C, Zielhuis G. Effects of a comprehensive self-management programme in patients with chronic obstructive pulmonary disease. Eur Respir J 2003; 22:815–820. 3. Hermiz O, Comino E, Marks G, Daffurn K, Wilson S, Harris M. Randomised controlled trial of home based care of patients with chronic obstructive pulmonary disease. BMJ 2002;325:938–942. 4. Bourbeau J, Julien M, Maltais F, Rouleau M, Beaupre A, Begin R, Renzi P, Nault D, Borycki E, Schwartzman K, et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a

disease-specific self-management intervention. Arch Intern Med 2003;163: 585–591. 5. Gallefoss F. The effects of patient education in COPD in a 1-year followup randomised, controlled trial. Patient Educ Couns 2004;52:259–266.

Dr. Wedzicha was given an opportunity to respond to this letter but declined to do so.

Fluoroquinolones in Multidrug-Resistant Tuberculosis To the Editor:

Chan and coworkers have shown a good outcome of treating multidrug-resistant tuberculosis (MDR TB) with fluoroquinolones (1). Fluoroquinolones have become indispensable in the treatment of MDR TB (2). As measured by their in vitro activity against Mycobacterium tuberculosis, the most potent of the currently available fluoroquinolones are, in descending order, moxifloxacin, gatifloxacin, levofloxacin, ofloxacin, and ciprofloxacin (1). The first three of these drugs are commonly known as antipneumococcal quinolones used in community-acquired pneumonia. M. tuberculosis clinical isolates that demonstrate high-level phenotypic resistance to fluoroquinolones, which appears to be predominantly due to gyrA mutations, exhibit cross-resistance to all six important fluoroquinolones (3). Patients with prior exposure to any of the quinolones are likely to develop resistance to other quinolones. Quinolones being broad spectrum antibacterial agents, their widespread and indiscriminate use, often in subtherapeutic doses, is likely to rapidly enhance quinolone-resistant organisms, including mycobacteria. MDR TB is increasing due to noninclusion of its treatment protocol in DOTS program. For a long time now there has been no new established drug available for MDR TB. At present we are left with few bacteriostatic antitubercular drugs. Reports of quinolone-resistant tuberculosis are constantly pouring in (4) and should act as a warning sign for the bleak future of cases of MDR-TB, because we are rapidly losing a very effective group of drugs for the management of such cases. So there should be some restriction on the use of fluoroquinolones, to save these drugs for future use in MDR TB. Preventing the emergence of antimicrobial resistance is certainly an important goal. In India (Delhi region), the combined prevalence of drug resistances during 1995 was 13.3% (5). However, even if 2% of new patients in India have MDR TB, this represents 20,000 new drug-resistant infectious cases every year. More than one million new patients with tuberculosis still do not have access to the basic program package in India (6). Identifying patients with MDR TB saves costs by providing effective treatment protocols without wasteful, unnecessary, and ineffective treatment. Furthermore, the primary cycle of MDR TB gets controlled, thereby saving the future funds and indirect costs that would otherwise have to be diverted for the treatment of both sick individuals and those they infect. Conflict of Interest Statement : P.R.M. does not have a financial relationship with a commercial entity that has an interest in the subject of this letter.

Prasanta Raghab Mohapatra Government Medical College Chandigarh, India References 1. Chan ED, Laurel V, Strand MJ, Chan JF, Huynh M-LN, Globe M, Iseman

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2.

3. 4.

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MD. Treatment and outcome analysis of 205 patients with multidrugresistant tuberculosis. Am J Respir Crit Care Med 2004;169:1103–1109. Mukherjee JS, Rich ML, Socci AR, Joseph JK, Viru FA, Shin SS, Furin JJ, Becerra MC, Barry DJ, Kim JY, et al. Programmes and principles in the treatment of multidrug-resistant tuberculosis. Lancet 2004;363: 474–481. Cheng AF, Yew WW, Chan EW, Chin ML, Hui MM, Chan RC. Antimicrob Agents Chemother 2004;48:596–601. Sullivan EA, Kreiswirth BN, Palumbo L, Kapur V, Musser JM, Ebrahimzadeh A, Frieden TR. Emergence of fluoroquinolone-resistant tuberculosis in New York City. Lancet 1995;345:1148–1150. Pablos-Mendez A, Raviglione MC, Laszlo A, Binkin N, Rieder HL, Bustreo F, Cohn DL, Lambregts-van Weezenbeek CS, Kim SJ, Chaulet P, et al. Global surveillance for antituberculosis-drug resistance, 1994–1997. World Health Organization-International Union against Tuberculosis and Lung Disease Working Group on Anti-Tuberculosis Drug Resistance Surveillance. N Engl J Med 1998;338:1641–1649. Khatri GR, Frieden TR. Controlling Tuberculosis in India. N Engl J Med 2002;347:1420–1425.

Dr. Michael Iseman was given the opportunity to respond to this letter but declined to do so.

Erratum: Nitric Oxide Diffusing Capacity From the Editor:

There were several errors in the article by Phansalkar and colleagues entitled “Nitric Oxide Diffusing Capacity and Alveolar Microvascular Recruitment in Sarcoidosis” (1). The regression equation at the end of the Figure 3 legend on p. 1038 was misstated. It should have read “Vc(modified RF) ⫽ 0.961 Vc(RF), r 2 ⫽ 0.636.” In addition, Dm should have been defined as “membrane diffusing capacity”; for this article, Vc should have been defined as “pulmonary capillary blood volume.” Finally, in Reference 16 on p. 1040, “C18O2” should have appeared as “C18O2.” These errors occurred during the production process by the

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publisher and are not the authors’ responsibility. The Journal apologizes for any confusion this may have created. Conflict of Interest Statement : E.A. is the Editor of the AJRCCM and receives a fixed stipend from the American Thoracic Society as Editor of the AJRCCM and does not receive financial support for research from pharmaceutical, biotechnology, or medical device companies and does not serve as a consultant for any pharmaceutical, biotechnology, or medical device company.

Edward Abraham Editor Reference 1. Phansalkar AR, Hanson CM, Shakir AR, Johnson RL Jr, Hsia CCW. Nitric oxide diffusing capacity and alveolar microvascular recruitment in sarcoidosis. Am J Respir Crit Care Med 2004;169:1034–1040.

Erratum: Chemokine Profiling in Pulmonary Fibrosis From the Editor:

In the September 1 editorial by Michael P. Keane (1) there was an error in the listing of authors. Dr. Keane should have been the only author listed; the phrase “and the other members of the Idiopathic Pulmonary Fibrosis study group” was inadvertently inserted. The error occurred in the final stages of production by the publisher. The Journal apologizes for any confusion this may have created. Conflict of Interest Statement : E.A. is the Editor of the AJRCCM and receives a fixed stipend from the American Thoracic Society as Editor of the AJRCCM and does not receive financial support for research from pharmaceutical, biotechnology, or medical device companies and does not serve as a consultant for any pharmaceutical, biotechnology, or medical device company.

Edward Abraham Editor Reference 1. Keane MP. Chemokine profiling in pulmonary fibrosis: ready for prime time? [editorial]. Am J Respir Crit Care Med 2004;170:475–476.