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Correspondence |

Mycobacterium tuberculosis in a Saudi Arabian Hospital FREE TO VIEW

Abdulrahman A. Alrajhi, MD
Author and Funding Information

Affiliations: King Faisal Specialist Hospital, Riyadh, Saudi Arabia,  Saudi Aramco Medical Services Organization, Dhahran, Saudi Arabia

Correspondence to: Abdulrahman A. Alrajhi, MD, Department of Medicine, King Faisal Specialist Hospital and Research Centre, MBC 46, PO Box 3354, Riyadh, Saudi Arabia 11211; e-mail: rajhi@kfshrc.edu.sa



Chest. 2006;129(3):829-830. doi:10.1378/chest.129.3.829
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To the Editor:

We read the article by Al-Tawfiq et al (November 2005)1 addressing the susceptibility of Mycobacterium tuberculosis in the Eastern Province of Saudi Arabia. We would like to make the following points:

1. Multidrug-resistant M tuberculosis (MDR-TB) was defined “as resistance to two or more first-line agents.” This is an erroneous definition. MDR-TB as defined by Centers for Diseases Control and Prevention, the World Health Organization, and the International Union against Tuberculosis and Lung Disease is resistance to at least isoniazid and rifampin with or without resistance to other agents.23

2. The authors indicated that there was only one report on M tuberculosis susceptibility from the Eastern Province.4In fact, Al-Jama et al5 reported on the susceptibility of 1,239 isolates of M tuberculosis from the Eastern province in 1999.

3. The rate of ethambutol resistance was higher than previously reported rates from all regions of Saudi Arabia. In our report6of all susceptibility data from Saudi Arabia, of 3,937 isolates tested against ethambutol, resistance was noted in 2.5% only, the lowest among all first-line agents tested in 6,316 isolates. Ethambutol resistance ranged between 0.5% and 6.9% in various regions. In a report by Kordy et al,7 ethambutol resistance was noted in 1.6% of 764 isolates from a single institute; the majority of the patients were Saudis. The reasons for such high rates of ethambutol resistance in the report by Al-Tawfiq et al1 need to be addressed.

4. The report does not indicate the proportion of patients with a new diagnosis of tuberculosis or have previously received antituberculosis chemotherapy. This is the most important risk factor for higher resistance rates. The rates of resistance can be several folds higher.7

5. Finally, data supporting the conclusion that “resistance to isoniazid showed decreased rate over the study period from 20 to 5.7%” were not presented in this report.

Al-Tawfiq, JA, Al-Muraikhy, AA, Abed, MS (2005) Susceptibility pattern and epidemiology ofMycobacterium tuberculosisin a Saudi Arabian hospital: a 15-year study from 1989 to 2003.Chest128,3229-3232. [CrossRef] [PubMed]
 
Prevention and treatment of tuberculosis among patients infected with human immunodeficiency virus: principles of therapy and revised recommendations.MMWR Morb Mortal Wkly Rep1998;47,1-51. [PubMed]
 
Schwoebel, V, Lambregts, CS, Moro, ML, et al European recommendations on surveillance of antituberculosis drug resistance.Euro Surveill2000;5,104-106. [PubMed]
 
Al-Rubaish, AM, Madania, AA, Al-Muhanna, FA Drug resistance pulmonary tuberculosis in the Eastern Province of Saudi Arabia.Saudi Med J2001;22,776-779. [PubMed]
 
Al-Jama, AA, Borgio, FG, Al-Qatari, KM Patterns of resistance to antituberculous drugs in Eastern Province, Saudi Arabia.Saudi Med J1999;20,927-930
 
Alrajhi, AA, Al-Barrak, AM Mycobacterium tuberculosissusceptibility in Saudi Arabia.Saudi Med J2002;23,1227-1231. [PubMed]
 
Kordy, FN, Al-Thawadi, S, Alrajhi, AA Drug resistance patterns ofMycobacterium tuberculosisin Riyadh, Saudi Arabia.Int J Tuberc Lung Dis2004;8,1007-1011. [PubMed]
 
To the Editor:

This letter is a reply to the points raised by Dr. Alrajhi regarding our recently published article in CHEST (November 2005).1The terminology used for resistant tuberculosis (TB) in the literature has included multidrug resistant (MDR), two-drug resistant, and polyresistant. MDR-TB refers to a subgroup of polyresistant organisms. We agree that MDR-TB is usually defined as resistance to at least isoniazid and rifampin with or without resistance to other agents. This is based on the fact that isoniazid and rifampin resistance is the most important type of resistance to first-line agents. However, the term MDR-TB has also been used to describe resistance to any two drugs.2 The variable use of MDR-TB was highlighted in an editorial comment by Sbarbaro,3 who noted that the term multidrug-resistant is used to identify organisms that are resistant to both isoniazid and rifampicin in the United States but is used more commonly in the rest of the world to include organisms that are resistant to any two or more antimycobacterial drugs.,3 We clearly defined multidrug resistance as resistance to two or more first-line agents. Our data also show that the rate of MDR is very low. If the definition of MDR is restricted to resistance to isoniazid and rifampicin, the rate of MDR-TB in the study would be 0.37 to 0.7%, as shown in Table 2 in our study.1

Unfortunately, the article by Al-Jama et al4 was not referenced on MEDLINE, and we did not come across that study. It was not our intent to omit the review of any pertinent published data, and we apologize for the omission. We also thank Dr. Alrajhi for bringing this study to our attention.

The rate of ethambutol resistance in our study was 7.5%,1 which is higher than the rate found in other studies from Saudi Arabia, including the study by Alrajhi and Al-Barrak.5However, the resistance rate to ethambutol found in our study is not very different from those reported from at least one region of Saudi Arabia. For example, the rate of ethambutol resistance in Jeddha was 6.9%.6 However, the exact reason for such a resistance rate could not be identified from the retrospective study.

The rates of resistance to antituberculous medications differ between newly diagnosed patients with TB and those who have received treatment. We could not track the details of any previous treatment. However, the majority of the patients had not received previous treatment for TB during the study period.

Although we stated in the abstract of our study1 that “resistance to isoniazid showed decreased rate over the study period from 20 to 5.7%,” the specific data were not shown in the study. We apologize for not including the specific data in the article.

References
Al-Tawfiq, JA, Al-Muraikhy, AA, Abed, MS Susceptibility pattern and epidemiology ofMycobacterium tuberculosisin a Saudi Arabian hospital: a 15-year study from 1989 to 2003.Chest2005;128,3229-3232. [CrossRef] [PubMed]
 
Kritski, AL, Rodrigues de Jesus, LS, Andrade, MK, et al Retreatment tuberculosis cases: factors associated with drug resistance and adverse outcomes.Chest1997;111,1162-1167. [CrossRef] [PubMed]
 
Sbarbaro, JA “Multidrug”-resistant tuberculosis: it is time to focus on the private sector of medicine.Chest1997;111,1149-1151. [CrossRef] [PubMed]
 
Al-Jama, AA, Borgio, FG, Al-Qatari, KM Patterns of resistance to antituberculous drugs in Eastern Province, Saudi Arabia.Saudi Med J1999;20,927-930
 
Alrajhi, AA, Al-Barrak, AM Mycobacterium tuberculosissusceptibility in Saudi Arabia.Saudi Med J2002;23,1227-1231. [PubMed]
 
Khan, MY, Kinsara, AG, Osoba, AO, et al Increasing resistance ofM tuberculosisto anti-TB drugs in Saudi Arabia.Int J Antimicrob Agents Chemother2001;17,415-418. [CrossRef]
 

Figures

Tables

References

Al-Tawfiq, JA, Al-Muraikhy, AA, Abed, MS (2005) Susceptibility pattern and epidemiology ofMycobacterium tuberculosisin a Saudi Arabian hospital: a 15-year study from 1989 to 2003.Chest128,3229-3232. [CrossRef] [PubMed]
 
Prevention and treatment of tuberculosis among patients infected with human immunodeficiency virus: principles of therapy and revised recommendations.MMWR Morb Mortal Wkly Rep1998;47,1-51. [PubMed]
 
Schwoebel, V, Lambregts, CS, Moro, ML, et al European recommendations on surveillance of antituberculosis drug resistance.Euro Surveill2000;5,104-106. [PubMed]
 
Al-Rubaish, AM, Madania, AA, Al-Muhanna, FA Drug resistance pulmonary tuberculosis in the Eastern Province of Saudi Arabia.Saudi Med J2001;22,776-779. [PubMed]
 
Al-Jama, AA, Borgio, FG, Al-Qatari, KM Patterns of resistance to antituberculous drugs in Eastern Province, Saudi Arabia.Saudi Med J1999;20,927-930
 
Alrajhi, AA, Al-Barrak, AM Mycobacterium tuberculosissusceptibility in Saudi Arabia.Saudi Med J2002;23,1227-1231. [PubMed]
 
Kordy, FN, Al-Thawadi, S, Alrajhi, AA Drug resistance patterns ofMycobacterium tuberculosisin Riyadh, Saudi Arabia.Int J Tuberc Lung Dis2004;8,1007-1011. [PubMed]
 
Al-Tawfiq, JA, Al-Muraikhy, AA, Abed, MS Susceptibility pattern and epidemiology ofMycobacterium tuberculosisin a Saudi Arabian hospital: a 15-year study from 1989 to 2003.Chest2005;128,3229-3232. [CrossRef] [PubMed]
 
Kritski, AL, Rodrigues de Jesus, LS, Andrade, MK, et al Retreatment tuberculosis cases: factors associated with drug resistance and adverse outcomes.Chest1997;111,1162-1167. [CrossRef] [PubMed]
 
Sbarbaro, JA “Multidrug”-resistant tuberculosis: it is time to focus on the private sector of medicine.Chest1997;111,1149-1151. [CrossRef] [PubMed]
 
Al-Jama, AA, Borgio, FG, Al-Qatari, KM Patterns of resistance to antituberculous drugs in Eastern Province, Saudi Arabia.Saudi Med J1999;20,927-930
 
Alrajhi, AA, Al-Barrak, AM Mycobacterium tuberculosissusceptibility in Saudi Arabia.Saudi Med J2002;23,1227-1231. [PubMed]
 
Khan, MY, Kinsara, AG, Osoba, AO, et al Increasing resistance ofM tuberculosisto anti-TB drugs in Saudi Arabia.Int J Antimicrob Agents Chemother2001;17,415-418. [CrossRef]
 
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