Comprehensive Treatment of Extensively Drug-Resistant Tuberculosis

doi:10.1056/NEJMoa0800106

Volume 359:563-574		August 7, 2008		Number 6

Comprehensive Treatment of Extensively Drug-Resistant Tuberculosis

Carole D. Mitnick, Sc.D., Sonya S. Shin, M.D., Kwonjune J. Seung, M.D., Michael L. Rich, M.D., Sidney S. Atwood, B.A., Jennifer J. Furin, M.D., Ph.D., Garrett M. Fitzmaurice, Sc.D., Felix A. Alcantara Viru, M.D., Sasha C. Appleton, Sc.M., Jaime N. Bayona, M.D., Cesar A. Bonilla, M.D., Katiuska Chalco, R.N., Sharon Choi, M.S., Molly F. Franke, B.A., Hamish S.F. Fraser, M.B., Ch.B., Dalia Guerra, Rocio M. Hurtado, M.D., Darius Jazayeri, M.S., Keith Joseph, M.D., Karim Llaro, R.N., Lorena Mestanza, R.N., Joia S. Mukherjee, M.D., Maribel Muñoz, R.N., Eda Palacios, R.N., Epifanio Sanchez, M.D., Alexander Sloutsky, Ph.D., and Mercedes C. Becerra, Sc.D.

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ABSTRACT

Background Extensively drug-resistant tuberculosis has beenreported in 45 countries, including countries with limited resourcesand a high burden of tuberculosis. We describe the managementof extensively drug-resistant tuberculosis and treatment outcomesamong patients who were referred for individualized outpatienttherapy in Peru.

Methods A total of 810 patients were referred for free individualizedtherapy, including drug treatment, resective surgery, adverse-eventmanagement, and nutritional and psychosocial support. We testedisolates from 651 patients for extensively drug-resistant tuberculosisand developed regimens that included five or more drugs to whichthe infecting isolate was not resistant.

Results Of the 651 patients tested, 48 (7.4%) had extensivelydrug-resistant tuberculosis; the remaining 603 patients hadmultidrug-resistant tuberculosis. The patients with extensivelydrug-resistant tuberculosis had undergone more treatment thanthe other patients (mean [±SD] number of regimens, 4.2±1.9vs. 3.2±1.6; P<0.001) and had isolates that were resistantto more drugs (number of drugs, 8.4±1.1 vs. 5.3±1.5;P<0.001). None of the patients with extensively drug-resistanttuberculosis were coinfected with the human immunodeficiencyvirus (HIV). Patients with extensively drug-resistant tuberculosisreceived daily, supervised therapy with an average of 5.3±1.3drugs, including cycloserine, an injectable drug, and a fluoroquinolone.Twenty-nine of these patients (60.4%) completed treatment orwere cured, as compared with 400 patients (66.3%) with multidrug-resistanttuberculosis (P=0.36).

Conclusions Extensively drug-resistant tuberculosis can be curedin HIV-negative patients through outpatient treatment, evenin those who have received multiple prior courses of therapyfor tuberculosis.

Source Information

From Harvard Medical School (C.D.M., H.S.F.F., M.C.B.), Brigham and Women's Hospital (S.S.S., S.S.A., J.J.F., G.M.F., R.M.H.), Partners in Health (K.J.S., M.L.R., S.C., D.J., K.J., J.S.M.), the Harvard School of Public Health (S.C.A., M.F.F.), and the Massachusetts State Laboratory Institute (A.S.) — all in Boston; and Socios en Salud (F.A.A.V., K.C., D.G., K.L., L.M., M.M., E.P., J.N.B.), the Peruvian Ministry of Health (C.A.B.), and Hospital Nacional Sergio E. Bernales (E.S.) — all in Lima, Peru.

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N Engl J Med 2008; 359:2390-2391, Nov 27, 2008. Correspondence

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