Antibiotic prophylaxis for preventing post solid organ transplant tuberculosis
Editorial Group: Cochrane Renal Group
Published Online: 4 MAR 2014
Assessed as up-to-date: 30 APR 2013
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Adamu B, Abdu A, Abba AA, Borodo MM, Tleyjeh IM. Antibiotic prophylaxis for preventing post solid organ transplant tuberculosis. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD008597. DOI: 10.1002/14651858.CD008597.pub2.
- Publication Status: New
- Published Online: 4 MAR 2014
Organ transplant recipients are at increased risk of infection as a result of immunosuppression caused inadvertently by medical treatment. Tuberculosis (TB) is a challenging infection to manage among organ transplant recipients that can be transmitted from infected people or triggered from latent infection. Organ transplant recipients have been reported to be up to 300 times more likely to develop TB than the general population. Consensus about the use of antibiotic prophylaxis to prevent post solid organ transplant TB has not been achieved.
This review assessed the benefits and harms of antibiotic prophylaxis to prevent post solid organ transplant TB.
We searched the Cochrane Renal Group's Specialised Register up to 30 April 2013 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE and handsearching conference proceedings.
All randomised controlled trials (RCTs) and quasi-RCTs that compared antibiotic prophylaxis with a placebo or no intervention for recipients of solid organ transplants were included.
Data collection and analysis
Two authors independently assessed studies for inclusion and extracted data. We derived risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data with 95% confidence intervals (CI). Methodological risk of bias was assessed using the Cochrane risk of bias tool.
We identified three studies (10 reports) that involved 558 kidney transplant recipients which met our inclusion criteria. All studies were conducted in countries that have high prevalence of TB (India and Pakistan), and investigated isoniazid, an oral antibacterial drug. Control in all studies was no antibiotic prophylaxis. Prophylactic administration of isoniazid reduced the risk of developing TB post-transplant (3 studies, RR 0.35 95% CI 0.14 to 0.89), and there was no significant effect on all-cause mortality (2 studies, RR 1.39, 95% CI 0.70 to 2.78). There was however substantial risk of liver damage (3 studies, RR 2.74, 95% CI 1.22 to 6.17).
Reporting of methodological quality parameters was incomplete in all three studies. Overall, risk of bias was assessed as suboptimal.
Isoniazid prophylaxis for kidney transplant recipients reduced the risk of developing TB post-transplant. Kidney transplant recipients in settings that have high prevalence of TB should receive isoniazid during the first year following transplant. There is however, significant risk of liver damage, particularly among those who are hepatitis B or C positive. Further studies are needed among recipients of other solid organ transplants and in settings with low prevalence of TB to determine the benefits and harms of anti-TB prophylaxis in those populations.
Plain language summary
Which drugs are most effective to prevent tuberculosis in organ transplant recipients?
Organ transplantation is often the best treatment option for patients with end-stage kidney, pancreas, heart, liver and lung disease. A major risk for transplant recipients is organ rejection. Although anti-rejection drugs improve survival, they weaken the immune system and increase the risk of infection, cancer, and cardiovascular disease.
Preventing and managing infection is a major challenge in organ transplant recipients. Tuberculosis (TB) is a particular concern because organ transplant recipients are up to 300 times more likely to contract this infection than people in the general population. TB can be difficult to diagnose because it can develop in different organs and body tissues aside from lungs.
We investigated whether drugs to prevent TB after transplant could reduce the disease in the post-transplant period. We found three studies that looked at 558 kidney transplant recipients in India and Pakistan where TB rates are high.
We found that taking the drug isoniazid (a tablet) during the first year after kidney transplant provided protection against developing TB. However, this drug also significantly increased the risk of liver damage. Most drug-related liver damage occurred in people who already had liver problems caused by hepatitis B or C. We also found that there was no difference in numbers of deaths from any cause between those who received the anti-TB drug and those who did not.
Although we found that isoniazid should be given to kidney transplant recipients in areas where TB is known to be a risk, further studies are needed in people who have received other organ transplants such as liver, lungs and heart, and where TB rates are low, to determine the wider benefits and harms of anti-TB drugs.
器官移植受贈者會因治療引發之無預期免疫抑制，導致感染風險增加。在器官移植受贈者治療上，結核病 (tuberculosis, TB) 是頗具挑戰性的感染症。結核病可經由已感染的患者傳染，或因潛伏性感染而觸發。曾有報告指出，器官移植受贈者罹患TB的機率，為一般群眾的300倍。醫學界對於使用抗生素預防療法來預防臟器移植後的TB，目前並未達成共識。
我們聯絡試驗搜尋協調員，使用與本文獻回顧有關的字彙，搜尋考科藍腎臟群組專業註冊 (Cochrane Renal Group's Specialised Register)截至2013年4月30日為止。透過專為CENTRAL、MEDLINE和EMBASE設計的搜尋策略，找出專業註冊所收錄的試驗，並以人工的方式搜尋研討會的會議記錄。
我們納入所有的隨機對照試驗(randomized controlled trial, RCT) 和半隨機對照試驗，研究對象為臟器移植受贈者，治療方法為抗生素預防療法、安慰劑或無任何治療介入。
由2位作者獨立評估試驗的納入資格和資料萃取。以風險比 (risk ratios, RR) 計算二元性資料，以平均差 (mean differences, MD) 計算連續資料，並報告95%信賴區間(confidence interval, CI)。利用考科藍偏差風險工具，評估方法學上的偏差風險。
有3篇試驗 (10篇論文) 符合我們的納入條件，包含558名腎臟移植受贈者。所有的試驗都在TB盛行率偏高的國家 (印度和巴基斯坦) 進行，試驗藥物為口服抗生素isoniazid。所有試驗的對照組患者，均未接受抗生素預防療法。soniazid預防療法可降低移植術後的TB罹病風險 (3篇試驗，RR為0.35，95% CI為014至0.89)，但對所有原因死亡 (all-cause mortality) 並無顯著影響 (2篇試驗，RR為1.39，95% CI為0.70至2.78)。不過肝臟受損的風險卻相當高 (3篇試驗，RR為2.74，95% CI為1.22至6.17)。
預防和治療感染症是器官移植受贈者的重大挑戰，其中又以結核病 (TB) 特別值得關注，因為器官移植受贈者的結核病罹病風險，為一般族群的300倍。TB很難診斷，因為除了肺部以外，身體其他器官和組織也可能感染TB。