FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 348:119-128 January 9, 2003 Number 2 Next

	Full Text PDF PDA Full Text PowerPoint Slide Set Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background 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.

Methods 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.

Results 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).

Conclusions 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.

Source Information

From the Program in Infectious Disease and Social Change, Harvard Medical School, Boston (C.M., J.B., S.S., J.F., M.B., M.C.S.F., J.Y.K., P.F.); the Harvard School of Public Health, Boston (C.M., S.K., D.N., J.H.M.); Partners In Health, Boston (C.M., J.B., S.S., J.F., M.B., M.C.S.F., J.Y.K., P.F.); Socios En Salud, Carabayllo, Lima, Peru (J.B., E.P., F.A.); the Division of Infectious Diseases, Brigham and Women's Hospital, Boston (S.S., J.H.M., P.F.); Hospital Sergio E. Bernales, Carabayllo, Lima, Peru (E.S.); and Servicios Basicos de Salud, Comas, Lima, Peru (M.S.).

Address reprint requests to Dr. Mitnick at the Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, 643 Huntington Ave., 4th Fl., Boston, MA 02115, or at carole_mitnick{at}hms.harvard.edu.

Full Text of this Article

This article has been cited by other articles:

• Wilson, D., Hurtado, R. M., Digumarthy, S. (2009). Case 18-2009 -- A 24-Year-Old Woman with AIDS and Tuberculosis with Progressive Cough, Dyspnea, and Wasting. NEJM 360: 2456-2464 [Full Text]  
• Basu, S., Friedland, G. H., Medlock, J., Andrews, J. R., Shah, N. S., Gandhi, N. R., Moll, A., Moodley, P., Sturm, A. W., Galvani, A. P. (2009). Averting epidemics of extensively drug-resistant tuberculosis. Proc. Natl. Acad. Sci. USA 106: 7672-7677 [Abstract] [Full Text]  
• Wilson, J. F. (2009). More Cases of Drug-Resistant Tuberculosis Complicate Care but Spur Global Research and Innovation. ANN INTERN MED 150: 433-436 [Full Text]  
• Shah, N. S., Pratt, R., Armstrong, L., Robison, V., Castro, K. G., Cegielski, J. P. (2008). Extensively Drug-Resistant Tuberculosis in the United States, 1993-2007. JAMA 300: 2153-2160 [Abstract] [Full Text]  
• Mitnick, C. D., Shin, S. S., Seung, K. J., Rich, M. L., Atwood, S. S., Furin, J. J., Fitzmaurice, G. M., Alcantara Viru, F. A., Appleton, S. C., Bayona, J. N., Bonilla, C. A., Chalco, K., Choi, S., Franke, M. F., Fraser, H. S.F., Guerra, D., Hurtado, R. M., Jazayeri, D., Joseph, K., Llaro, K., Mestanza, L., Mukherjee, J. S., Munoz, M., Palacios, E., Sanchez, E., Sloutsky, A., Becerra, M. C. (2008). Comprehensive Treatment of Extensively Drug-Resistant Tuberculosis. NEJM 359: 563-574 [Abstract] [Full Text]  
• Raviglione, M. C. (2008). Facing Extensively Drug-Resistant Tuberculosis -- A Hope and a Challenge. NEJM 359: 636-638 [Full Text]  
• Somocurcio, J. G, Sotomayor, A., Shin, S., Portilla, S., Valcarcel, M., Guerra, D., Furin, J. (2007). Surgery for patients with drug-resistant tuberculosis: report of 121 cases receiving community-based treatment in Lima, Peru. Thorax 62: 416-421 [Abstract] [Full Text]  
• KAWAI, V., SOTO, G., GILMAN, R. H., BAUTISTA, C. T., CAVIEDES, L., HUAROTO, L., TICONA, E., ORTIZ, J., TOVAR, M., CHAVEZ, V., RODRIGUEZ, R., ESCOMBE, A. R., EVANS, C. A. (2006). TUBERCULOSIS MORTALITY, DRUG RESISTANCE, AND INFECTIOUSNESS IN PATIENTS WITH AND WITHOUT HIV INFECTION IN PERU. Am J Trop Med Hyg 75: 1027-1033 [Abstract] [Full Text]  
• Chiang, C-Y., Enarson, D. A., Yu, M-C., Bai, K-J., Huang, R-M., Hsu, C-J., Suo, J., Lin, T-P. (2006). Outcome of pulmonary multidrug-resistant tuberculosis: a 6-yr follow-up study. Eur Respir J 28: 980-985 [Abstract] [Full Text]  
• Moore, D. A.J., Evans, C. A.W., Gilman, R. H., Caviedes, L., Coronel, J., Vivar, A., Sanchez, E., Pinedo, Y., Saravia, J. C., Salazar, C., Oberhelman, R., Hollm-Delgado, M.-G., LaChira, D., Escombe, A. R., Friedland, J. S. (2006). Microscopic-Observation Drug-Susceptibility Assay for the Diagnosis of TB.. NEJM 355: 1539-1550 [Abstract] [Full Text]  
• Kim, H. J., Kang, C. H., Kim, Y. T., Sung, S-W., Kim, J. H., Lee, S. M., Yoo, C-G., Lee, C-T., Kim, Y. W., Han, S. K., Shim, Y-S., Yim, J-J. (2006). Prognostic factors for surgical resection in patients with multidrug-resistant tuberculosis. Eur Respir J 28: 576-580 [Abstract] [Full Text]  
• Sharma, S. K., Mohan, A. (2006). Multidrug-resistant tuberculosis: a menace that threatens to destabilize tuberculosis control.. Chest 130: 261-272 [Abstract] [Full Text]  
• Drobac, P. C., Mukherjee, J. S., Joseph, J. K., Mitnick, C., Furin, J. J., del Castillo, H., Shin, S. S., Becerra, M. C. (2006). Community-based therapy for children with multidrug-resistant tuberculosis.. Pediatrics 117: 2022-2029 [Abstract] [Full Text]  
• (2006). Emergence of Mycobacterium tuberculosis With Extensive Resistance to Second-Line Drugs--Worldwide, 2000-2004. JAMA 295: 2349-2351 [Full Text]  
• Holtz, T. H., Sternberg, M., Kammerer, S., Laserson, K. F., Riekstina, V., Zarovska, E., Skripconoka, V., Wells, C. D., Leimane, V. (2006). Time to Sputum Culture Conversion in Multidrug-Resistant Tuberculosis: Predictors and Relationship to Treatment Outcome. ANN INTERN MED 144: 650-659 [Abstract] [Full Text]  
• Cohen, T., Lipsitch, M., Walensky, R. P., Murray, M. (2006). Beneficial and perverse effects of isoniazid preventive therapy for latent tuberculosis infection in HIV-tuberculosis coinfected populations. Proc. Natl. Acad. Sci. USA 103: 7042-7047 [Abstract] [Full Text]  
• Dye, C., Watt, C. J., Bleed, D. M., Hosseini, S. M., Raviglione, M. C. (2005). Evolution of Tuberculosis Control and Prospects for Reducing Tuberculosis Incidence, Prevalence, and Deaths Globally. JAMA 293: 2767-2775 [Abstract] [Full Text]  
• Caminero, J. A. (2005). Management of multidrug-resistant tuberculosis and patients in retreatment. Eur Respir J 25: 928-936 [Abstract] [Full Text]  
• Falzari, K., Zhu, Z., Pan, D., Liu, H., Hongmanee, P., Franzblau, S. G. (2005). In Vitro and In Vivo Activities of Macrolide Derivatives against Mycobacterium tuberculosis. Antimicrob. Agents Chemother. 49: 1447-1454 [Abstract] [Full Text]  
• Martin, A., Palomino, J. C., Portaels, F. (2005). Rapid Detection of Ofloxacin Resistance in Mycobacterium tuberculosis by Two Low-Cost Colorimetric Methods: Resazurin and Nitrate Reductase Assays. J. Clin. Microbiol. 43: 1612-1616 [Abstract] [Full Text]  
• Di Perri, G., Bonora, S. (2004). Which agents should we use for the treatment of multidrug-resistant Mycobacterium tuberculosis?. J Antimicrob Chemother 54: 593-602 [Abstract] [Full Text]  
• Paton, N. I, Chua, Y.-K., Earnest, A., Chee, C. B. (2004). Randomized controlled trial of nutritional supplementation in patients with newly diagnosed tuberculosis and wasting. Am. J. Clin. Nutr. 80: 460-465 [Abstract] [Full Text]  
• Griffith, D. E. (2004). Treatment of Multidrug-resistant Tuberculosis: Should You Try This at Home?. Am. J. Respir. Crit. Care Med. 169: 1082-1083 [Full Text]  
• Shin, S., Furin, J., Alcantara, F., Hyson, A., Joseph, K., Sanchez, E., Rich, M. (2004). Hypokalemia Among Patients Receiving Treatment for Multidrug-Resistant Tuberculosis. Chest 125: 974-980 [Abstract] [Full Text]  
• Campos, N. G., Farmer, P. (2003). Partners: Discernment and Humanitarian Efforts in Settings of Violence. J Law Med Ethics 31: 506-515  
• Martin, A., Camacho, M., Portaels, F., Palomino, J. C. (2003). Resazurin Microtiter Assay Plate Testing of Mycobacterium tuberculosis Susceptibilities to Second-Line Drugs: Rapid, Simple, and Inexpensive Method. Antimicrob. Agents Chemother. 47: 3616-3619 [Abstract] [Full Text]  
• Nardell, E. A (2003). Impact of DOTS and DOTS-plus on multidrug resistant TB: DOTS-plus strengthens, not weakens, DOTS programmes. BMJ 327: 164-164 [Full Text]  
• Sterling, T. R, Lehmann, H. P, Frieden, T. R (2003). Impact of DOTS and DOTS-plus on multidrug resistant TB: Authors' reply. BMJ 327: 164-164 [Full Text]  
• Dheda, K (2003). Community based outpatient treatment of multidrug-resistant tuberculosis. Thorax 58: 347-347 [Full Text]  
• Noah, B. A. (2003). AIDS and Antiretroviral Drugs in South Africa: Public Health, Politics, and Individual Suffering: A Review of Brian Tilley's It's My Life. J Law Med Ethics 31: 144-148  
• (2003). Successful Treatment of Multidrug-Resistant TB in Peru. JWatch Infect. Diseases 2003: 1-1 [Full Text]  
• (2003). American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: Treatment of Tuberculosis. Am. J. Respir. Crit. Care Med. 167: 603-662 [Full Text]