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Background The aim of this study was to evaluate C-reactive protein(CRP), globulin and white cell count as predictors of treatment outcome in pulmonary tuberculosis. Methods An observational study of patients with active pulmonary tuberculosis was conducted at a tertiary centre. All patients had serum CRP, globulin and white cell count measured at baseline and two months following commencement of therapy. The outcome of interest was requirement for extension of therapy beyond 6 months. Results There were 226 patients included in the study. Serum globulin >45 g/L was the only baseline biomarker evaluated that independently predicted requirement for therapy extension (OR 3.59 (1.79–7.57; p Conclusions Serum globulin independently predicts requirement for treatment extension in pulmonary TB and outperforms CRP and white cell count as a predictive biomarker. Normalisation of globulin at two months following treatment commencement is associated with low risk of requirement for treatment extension.

Introduction Non-Tuberculous Mycobacteria (NTM) are ubiquitous in the environment meaning clinical, radiological and microbiological criteria are important in diagnosing NTM lung disease. A multicentre, retrospective review was performed to characterise NTM disease within our region and describe the outcomes of current management. Methods All NTM positive sputum samples received by the National Mycobacterium Reference Laboratory (NMRL) from Imperial College NHS Healthcare and North West London Hospitals NHS Trusts between 2010–2014 were extracted. HIV-negative individuals with ≥2 positive sputum samples or ≥1 positive bronchoalveolar lavage were included. Demographic, clinical, radiological, microbiological, management and outcome data was obtained from electronic records. Results 1190 NTM sputum samples were identified from 822 individuals. 152 individual patients met inclusion criteria for analysis. Table 1 describes cohort demographics. Within the cohort 48/152 (32%) were treated for NTM disease. All treated subjects and 74/104 (71%) non-treated subjects met international guidelines for diagnosis of NTM infection, which included positive clinical, radiological (cavities or bronchiectasis +/- nodules or infiltrates) and microbiological criteria. Mycobacterium avium complex (MAC) was the most commonly isolated (68/152; 45%) and treated organism (21/48; 44%) followed by Mycobacterium kansasii (11/48; 23%). 19/48 (40%) completed treatment (median duration: 17 months [IQR: 12–24]). 10/48 (21%) remain on treatment (median duration: 18 months [IQR: 11–36]), 11/48 (23%) stopped treatment due to side effects and 13/48 (27%) were either lost to follow up or treated for Mycobacterium tuberculosis . Of those treated, 29/48 (60%) culture converted; 23/29 (79%) remain negative at 12 months post culture conversion. Of 19/48 who completed treatment, 5/19 (26%) had symptomatic or radiological disease progression compared to 11/28 (39%) who did not complete treatment. 11/48 (23%) patients died within the treatment group. Within the untreated subjects who met international guidelines for NTM infection (74/104), mortality was 19/74 (26%) (p = 0.83). Discussion NTM is a challenging disease with only 39% of eligible subjects receiving treatment and a high associated mortality. Furthermore, only 40% starting treatment completed it and the 21% who remain on treatment have been treated for a median duration of 18 months to date. Unlike similar HIV-negative UK cohorts, MAC pulmonary disease is the most prevalent.

Introduction We describe the incidence and management of drug induced liver injury (DILI) in active TB at the largest UK centre, using a nurse-led local protocol derived from 1998 BTS guidelines. Methods All active TB cases were identified from April 2010 to May 2014. Patients were identified with DILI by following criteria: Type 1 DILI(ALT >3x upper limit normal (ULN-55iu/l), Type 2 DILI (ALP >2x ULN(150 iu/l) and Bilirubin >21 iu/l) or Type 3 DILI (Bilirubin >40 iu/l). Patient demographics, TB treatment (ATT), timing, management and outcomes of DILI were described. Baseline characteristics and ATT doses were matched with controls. Results 105 individuals with DILI were identified out of 1529 patients with active TB (6.9%). 81% were on standard first line therapy (Rifampicin (R), Isoniazid (H), Pyrazinamide (Z) and Ethambutol (E)). 7.8% were on Moxifloxacin (M) instead of E and 1.9% were on RHME. Type 1 DILI was most frequent (81%) with median peak ALT 296 iu/l (IQR 227–505). Median time from treatment start to onset of DILI was 12.5 days (7–30). Symptoms at presentation included nausea/vomiting (54%), abdominal pain (18%) and jaundice (12.4%). 45.7% patients had all medication stopped, 7.6% continued ethambutol with amikacin (A), 26.7% continued all medication, 6.7% stopped Z only, 3.8% substituted Z for a quinolone. Median time from stopping to reintroduction was 10 days (6–17). Of 66 reintroduction patients, regimens included H >R >E(45%), H>R>E>M (31%) and R>E>M (15%). Median time from reintroduction to full treatment restart was 14 days (12–18). 81% of patients were uneventfully reintroduced, 5% suffered a 2nd DILI. 32% patients required hospital admission and 4(3.8%) died. DILI cases were matched to 200 controls. Cases more likely (P Conclusion DILI remains the most important toxicity of ATT and usually occurs during the first month. The BTS guideline provides a useful template for the diagnosis and management of DILI which may be largely nurse led and ambulatory. Most patients are successfully reintroduced without pyrazinamide. HIV status, body weight and quinolone use are risk factors.