C304 - Effectiveness and Safety of Rifamycin-Sparing versus Rifamycin-Containing Regimens for Tuberculosis in Solid Organ Transplant Recipients: A Systematic Review and Meta-Analysis

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Author Block: J. Bruminhent¹, W. Wathanavasin², W. Cheungpasitporn³, S. Kantachuvesiri⁴, ¹Division of Infectious Diseases, Department of Medicinee, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, ²Charoenkrung Pracharak Hospital, Bangkok, Thailand, ³Mayo Clinic, Rochester, MN, ⁴Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
*Purpose: Tuberculosis (TB) remains a clinically significant challenge after solid organ transplantation (SOT). Although rifamycins are essential to TB treatment, their strong induction of cytochrome P450 enzymes leads to substantial drug-drug interactions with calcineurin and mTOR inhibitors. As a result, rifamycin-sparing regimens are frequently used, yet their comparative effectiveness and safety in SOT recipients are not well defined. This study systematically evaluated outcomes of rifamycin-containing versus rifamycin-sparing regimens for active TB after SOT.
*Methods: A systematic review was conducted according to PRISMA guidelines. MEDLINE, Embase, Scopus, Web of Science, and Cochrane CENTRAL were searched through October 2025 using terms related to TB, solid organ transplantation, rifamycins, and rifamycin-sparing alternatives. Eligible studies included ≥3 SOT recipients with regimen-specific outcomes. Data from 12 studies were synthesized using random-effects meta-analysis.
*Results: A total of 230 SOT recipients with active TB were identified: 127 received rifamycin-containing regimens and 103 received rifamycin-sparing regimens. Treatment success occurred in 85.8% (109/127) and 89.0% (73/82) of patients, respectively. Success rates were not significantly different (pooled OR 1.54; 95% CI 0.65-3.66; p = 0.32) (Figure 1). Mortality was 14.2% (18/127) in the rifamycin group versus 11.0% (9/82) in the rifamycin-sparing group, with no significant difference (pooled OR 0.65; 95% CI 0.27-1.54; p = 0.32). Rifamycin-sparing approaches—particularly fluoroquinolone-based combinations and rifabutin substitution—were associated with fewer interaction-related complications, though data were limited.
*Conclusions: Rifamycin-sparing regimens appear to provide effectiveness and mortality outcomes comparable to rifamycin-containing therapy for active TB in SOT recipients. However, the current evidence is constrained by small sample sizes, heterogeneity in regimen choice, and potential confounding. Prospective, transplant-specific studies are needed to better define optimal TB treatment strategies in this high-risk population.