THE PREVALENCE OF PULMONARY CAVITATION IN MULTIDRUG-RESISTANT TUBERCULOSIS AND ITS IMPACT ON TREATMENT DURATION A SYSTEMATIC REVIEW OF RANDOMISED CONTROLLED TRIALS AND PRIMARY STUDIES

Abstract

Introduction: Pulmonary cavitation is the radiological hallmark of high-burden tuberculosis and the most influential imaging predictor of microbiological response in multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB). Despite its centrality to regimen selection and shortened-regimen eligibility, no synthesis has simultaneously quantified cavitation frequency and its impact on treatment duration.

Methods: The study strictly adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines, including RCTs, cohort, case-control, and cross-sectional studies. Risk of bias assessed with RoB 2, NOS, AXIS, and QUADAS-2. Effects pooled using DerSimonian-Laird random-effects models; heterogeneity with I²; discrimination by binormal ROC reconstruction.

Results: Twenty-five studies (8 RCTs, 16 cohorts, 1 radiomic) encompassing >12,000 MDR/RR-TB patients were included. Cavitation prevalence was 60.7% in the largest multinational estimate. Cavitation reduced sputum culture conversion hazard (HR 0.58; 95% CI 0.39–0.85; p=0.0054), prolonging conversion time approximately 1.73-fold (+27 days). Cavitation reduced 2-month conversion (OR 0.35; p=0.006) and 6-month conversion probability from 0.89 to 0.68 (p=0.0004). Cavitation was associated with unfavourable outcome (OR 6.17; 95% CI 3.83–9.93; p<0.0001), recurrence (HR 6.3), mortality, culture reversion, and bedaquiline resistance (RR 1.8; p=0.02). Every contemporary shortened regimen used cavitation in stratification or duration-extension rules. Binary cavitation discriminated poorly (AUC 0.53), but cavity radiomics achieved AUC 0.84–0.83 vs 0.59–0.50 for clinical models.

Conclusion: Pulmonary cavitation affects three in five MDR/RR-TB patients and is independently associated with delayed conversion, unfavourable outcome, recurrence, and acquired resistance, prolonging effective treatment duration. Cavitation should be quantitatively documented and embedded in composite prediction models.