Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru


Mitnick, C; Bayona, J; Palacios, E; Shin, S; Furin, J; Alcántara, F; Sánchez, E; Sarria, M; Becerra, M; Fawzi, MC; Kapiga, S; Neuberg, D; Maguire, JH; Kim, JY; Farmer, P; (2003) Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. The New England journal of medicine, 348 (2). pp. 119-28. ISSN 0028-4793 DOI: https://doi.org/10.1056/NEJMoa022928

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Abstract

: Despite the prevalence of multidrug-resistant tuberculosis in nearly all low-income countries surveyed, effective therapy has been deemed too expensive and considered not to be feasible outside referral centers. We evaluated the results of community-based therapy for multidrug-resistant tuberculosis in a poor section of Lima, Peru.<br/> : We describe the first 75 patients to receive ambulatory treatment with individualized regimens for chronic multidrug-resistant tuberculosis in northern Lima. We conducted a retrospective review of the charts of all patients enrolled in the program between August 1, 1996, and February 1, 1999, and identified predictors of poor outcomes.<br/> : The infecting strains of Mycobacterium tuberculosis were resistant to a median of six drugs. Among the 66 patients who completed four or more months of therapy, 83 percent (55) were probably cured at the completion of treatment. Five of these 66 patients (8 percent) died while receiving therapy. Only one patient continued to have positive cultures after six months of treatment. All patients in whom treatment failed or who died had extensive bilateral pulmonary disease. In a multiple Cox proportional-hazards regression model, the predictors of the time to treatment failure or death were a low hematocrit (hazard ratio, 4.09; 95 percent confidence interval, 1.35 to 12.36) and a low body-mass index (hazard ratio, 3.23; 95 percent confidence interval, 0.90 to 11.53). Inclusion of pyrazinamide and ethambutol in the regimen (when susceptibility was confirmed) was associated with a favorable outcome (hazard ratio for treatment failure or death, 0.30; 95 percent confidence interval, 0.11 to 0.83).<br/> : Community-based outpatient treatment of multidrug-resistant tuberculosis can yield high cure rates even in resource-poor settings. Early initiation of appropriate therapy can preserve susceptibility to first-line drugs and improve treatment outcomes.<br/>

Item Type: Article
Keywords: Adult, Ambulatory Care, Antitubercular Agents/*therapeutic use, *Community Health Services, Developing Countries, *Directly Observed Therapy, Female, Humans, Male, Microbial Sensitivity Tests, Peru, Proportional Hazards Models, Retrospective Studies, Treatment Outcome, Tuberculosis, Multidrug-Resistant/*drug therapy/microbiology, Adult, Ambulatory Care, Antitubercular Agents, therapeutic use, Community Health Services, Developing Countries, Directly Observed Therapy, Female, Humans, Male, Microbial Sensitivity Tests, Peru, Proportional Hazards Models, Research Support, Non-U.S. Gov't, Research Support, U.S. Gov't, P.H.S., Retrospective Studies, Treatment Outcome, Tuberculosis, Multidrug-Resistant, drug therapy, microbiology
Faculty and Department: Faculty of Epidemiology and Population Health > Dept of Infectious Disease Epidemiology
Research Centre: Centre for Global Non-Communicable Diseases (NCDs)
PubMed ID: 12519922
Web of Science ID: 180263900004
URI: http://researchonline.lshtm.ac.uk/id/eprint/9891

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