Abstract
SettingKibong’oto National Tuberculosis Hospital (KNTH), Kilimanjaro, Tanzania.ObjectiveCharacterize the diagnostic process and interim treatment outcomes from patients treated for multidrug-resistant tuberculosis (MDR-TB) in Tanzania.DesignA retrospective cohort study was performed among all patients treated at KNTH for pulmonary MDR-TB between November 2009 and September 2011.ResultsSixty-one culture-positive MDR-TB patients initiated therapy, 60 (98%) with a prior history of TB treatment. Forty-one (67%) were male and 9 (14%) were HIV infected with a mean CD4 count of 424 (±106) cells/µl. The median time from specimen collection to MDR-TB diagnosis and from diagnosis to initiation of MDR-TB treatment was 138 days (IQR 101–159) and 131 days (IQR 32–233), respectively. Following treatment initiation four (7%) patients died (all HIV negative), 3 (5%) defaulted, and the remaining 54 (89%) completed the intensive phase. Most adverse drug reactions were mild to moderate and did not require discontinuation of treatment. Median time to culture conversion was 2 months (IQR 1–3) and did not vary by HIV status. In 28 isolates available for additional second-line drug susceptibility testing, fluoroquinolone, aminoglycoside and para-aminosalicylic acid resistance was rare yet ethionamide resistance was present in 9 (32%).ConclusionThe majority of MDR-TB patients from this cohort had survived a prolonged referral process, had multiple episodes of prior TB treatment, but did not have advanced AIDS and converted to culture negative early while completing an intensive inpatient regimen without serious adverse event. Further study is required to determine the clinical impact of second-line drug susceptibility testing and the feasibility of alternatives to prolonged hospitalization.
Highlights
Multidrug-resistant tuberculosis (MDR-TB), defined as resistance to both isoniazid and rifampin, remains poorly diagnosed and treated [1]
Sixty-one (87%) patients were referred based on routine clinical practice/physician suspicion, while the remainder by drugresistance surveillance or independent research, including 8 (12%) for whom initial screening susceptibility was made by molecular detection of drug-resistant mutations for isoniazid and rifampin (MTBDRplus, Hain Lifescience, Nehren, Germany)
For two patients initial drug susceptibility testing results could not be confirmed and another 3 patients were found to have a M. tuberculosis isolate which was sensitive to isoniazid or rifampin, and excluded from the analysis
Summary
Multidrug-resistant tuberculosis (MDR-TB), defined as resistance to both isoniazid and rifampin, remains poorly diagnosed and treated [1]. The second-line drugs used in the treatment of MDR-TB have only recently been available in many TB endemic countries following WHO rollout initiatives. Analysis of outcomes from diverse settings with recent access to MDR-TB treatment is critical for study of comparative efficacy and for design of similar programs in other emerging locations. Data on drug-resistance are limited, a recent cluster survey placed the prevalence from MDR-TB among retreatment cases at only 3.9% [5]. Treatment for MDR-TB was made available in 2009 and the Ministry of Health selected Kibong’oto National Tuberculosis Hospital (KNTH) in the Kilimanjaro region of Northern Tanzania as the initial referral hospital for all MDR-TB cases [6].
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