The Efficacy of Isoniazid Prophylaxis in Renal Transplant Recipients in a High TB Burden Country

IntroductionRenal transplant recipients are at high risk of tuberculosis (TB). We have started Isoniazid (INH) prophylaxis of 1 year duration in all renal transplant recipients from April 2009. Our aim is to assess the incidence of TB on INH prophylaxis and its tolerability.MethodsThis was a retrospective observational study. The files of renal transplant recipients from April 2009 to December 2011 were reviewed till June 2015. We noted the incidence of TB, INH tolerability and development of resistance. We compared the incidence of TB with the historical controls who never received the prophylaxis.ResultsA total of 910 patients were reviewed and followed for 4.8 years. INH prophylaxis was completed by 825 (91%) patients. A total of 46 patients (5%) developed active TB as compared to 15% in the historical controls. The median time of TB diagnosis from transplantation was 2.8 years. In the first-year post transplant, out of total TB cases, 52% occurred in the historical controls whereas 13% occurred in study cohort. Around 67% had TB > 2 years after transplant. Overall 1.43% had hepatotoxicity. There was a significant reduction in TB among those who completed prophylaxis to those who did not (p=0.02). Out of 14 cultures one isolate was INH resistant (7%).ConclusionINH prophylaxis is well tolerated. The incidence of TB has decreased during the first 2 years. However there was a surge in TB cases 1 year after stopping INH therapy. We should consider prolonging the duration of INH prophylaxis in high TB burden countries in renal transplant recipients.

Tuberculosis in Pregnancy: A Review

Tuberculosis (TB) was declared a public health emergency by WHO in 2005. The disease is a significant contributor to maternal mortality and is among the three leading causes of death among women aged 15–45 years in high burden areas. The exact incidence of tuberculosis in pregnancy, though not readily available, is expected to be as high as in the general population. Diagnosis of tuberculosis in pregnancy may be challenging, as the symptoms may initially be ascribed to the pregnancy, and the normal weight gain in pregnancy may temporarily mask the associated weight loss. Obstetric complications of TB include spontaneous abortion, small for date uterus, preterm labour, low birth weight, and increased neonatal mortality. Congenital TB though rare, is associated with high perinatal mortality. Rifampicin, INH and Ethambutol are the first line drugs while Pyrazinamide use in pregnancy is gaining popularity. Isoniazid preventive therapy is a WHO innovation aimed at reducing the infection in HIV positive pregnant women. Babies born to this mother should be commenced on INH prophylaxis for six months, after which they are vaccinated with BCG if they test negative. Successful control of TB demands improved living conditions, public enlightenment, primary prevention of HIV/AIDS and BCG vaccination.

Isoniazid-Induced Severe Hepatotoxicity: An Infrequent but Preventable Cause of Liver Failure in Children Treated for Latent Tuberculosis Infection

Isoniazid (INH) monotherapy has gained widespread acceptance as an efficacious therapy for latent tuberculosis infection (LTBI) especially in low-prevalence settings. Although INH related hepatotoxicity is well recognized, progression to severe liver dysfunction requiring care at a transplant center remains unpredictable. We report the management of a five year-old girl who developed progressive liver failure due to INH prophylaxis. This highlights the potential severity of INH related hepatic injury and underscores the significance of vigilant clinical monitoring throughout the duration of the therapy in children.

Reduction of clinical tuberculosis in HIV-infected males with isoniazid prophylaxis

Isoniazid [INH] chemoprophylaxis has a positive impact on the development of clinical tuberculosis. Due to the increased prevalence of tuberculosis among HIV-infected individuals, we evaluated the effect of INH on the prevention of clinical tuberculosis in HIV-infected patients. We administered 300 mg of INH daily to 246 HIV-infected, tuberculin skin test-positive patients for 12 months. During 3 years of follow-up, 41 participants died and 94 were lost to follow up. Of the 111 patients followed for the 3 years, 12 developed tuberculosis which is lower than might be expected in an untreated group. INH prophylaxis appears to be an effective method to prevent clinical tuberculosis among HIV-infected, tuberculin skin test-positive patients.

Amphotericin—How Safe and Effective?

Over a period of 35 days beginning July 23, 1984, the Infection Control Section of the Nassau Hospital, a 535-bed community teaching institution received reports of an unusually high number of PPD tuberculin skin test conversions among employees from Employee Health Service personnel.The first case involved a registered nurse who, upon receiving a routine annual Mantoux skin test on July 23, converted from the previous year's negative reaction to a significant reaction (20 mm induration) with a greater than normal area of erythema. When she reported this to her private medical doctor prior to beginning INH prophylaxis, she was retested by the physician. This test was read as nonreactive.