Abstract
IntroductionIn high multidrug resistant (MDR) tuberculosis (TB) prevalence areas, drug susceptibility testing (DST) at diagnosis is recommended for patients with risk factors for MDR. However, this approach might miss a substantial proportion of MDR-TB in the general population. We studied primary MDR in patients considered to be at low risk of MDR-TB in Lima, Peru.MethodsWe enrolled new sputum smear-positive TB patients who did not report any MDR-TB risk factor: known exposure to a TB patient whose treatment failed or who died or who was known to have MDR-TB; immunosuppressive co-morbidities, ex prison inmates; prison and health care workers; and alcohol or drug abuse. A structured questionnaire was applied to all enrolled participants to confirm the absence of these factors and thus minimize underreporting. Sputum from all participants was cultured on Löwenstein-Jensen media and DST for first line drugs was performed using the 7H10 agar method.ResultsOf 875 participants with complete data, 23.2% (203) had risk factors for MDR-TB elicited after enrolment. Among the group with no reported risk factors who had a positive culture, we found a 6.3% (95%CI 4.4–8.3) (37/584) rate of MDR-TB. In this group no epidemiological characteristics were associated with MDR-TB. Thus, in this group, multidrug resistance occurred in patients with no identifiable risk factors.ConclusionsWe found a high rate of primary MDR-TB in a general population with no identifiable risk factors for MDR-TB. This suggests that in a high endemic area targeting patients for MDR-TB based on the presence of risk factors is an insufficient intervention.
Highlights
In high multidrug resistant (MDR) tuberculosis (TB) prevalence areas, drug susceptibility testing (DST) at diagnosis is recommended for patients with risk factors for MDR
In order to contribute with evidence for enhanced MDR case detection strategies, we aimed to evaluate the yield of testing low risk patients living in a high MDR burden area
Sputum culture and DST for first line drugs are routinely requested for any retreatment category; persons reporting exposure to a MDR-TB case or to a TB case that failed treatment or that died during treatment; patients with immunosuppressive co-morbidities such as HIV and diabetes; persons working or admitted in a prison; health care workers, and persons with a recent and prolonged admission to a hospital [8]
Summary
In high multidrug resistant (MDR) tuberculosis (TB) prevalence areas, drug susceptibility testing (DST) at diagnosis is recommended for patients with risk factors for MDR. This approach might miss a substantial proportion of MDR-TB in the general population. Tailored case detection strategies for DR TB are required to maximize diagnostic efficiency and the rational use of financial, human and infrastructure resources The objective of this approach is early detection of DR patients which in turn should allow early initiation of appropriate TB treatment regimens with prevention of clinical deterioration and reduction of transmission of DR strains. DR testing is recommended in certain populations: HIV-positive patients in areas where HIV is associated with DR, prisoners, and in persons living in areas with high DR prevalence [3,4]
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