The relationship between delayed or incomplete treatment and all-cause mortality in patients with tuberculosis.
OBJECTIVE
To analyze the factors associated with survival in patients with pulmonary and extrapulmonary tuberculosis in New York City.


METHODS
Observational study of a citywide cohort of tuberculosis cases.


METHODS
New York City, April 1991, before the strengthening of its control program.


METHODS
All 229 newly diagnosed cases of tuberculosis documented by culture in April 1991. Most patients (74%) were male, and the median age was 37 years (range, 1-89 years). In all, 89% belonged to minority groups. Human immunodeficiency virus (HIV) infection was present in 50% and multidrug resistance in 7% of the cases. Twenty-one patients (9%) were not treated.


METHODS
Follow-up information was collected through the New York City tuberculosis registry; death from any cause was verified through the National Death Index.


RESULTS
Cumulative all-cause mortality by October 1994 was 44%; the median survival for those who died was 6.3 months (range, 0 days to 3 years). The most important baseline predictors of mortality, adjusted for baseline clinical and demographic factors, were acquired immunodeficiency syndrome (AIDS) (91% vs 11% in HIV-seronegative patients; Cox relative risk [RR], 7.8; 95% confidence interval [CI], 2.1-29.1), multidrug resistance (87% vs 39% in pansensitive cases; adjusted RR, 5.8; 95% CI, 2.3-14.5), and lack of treatment (81% vs 40%; adjusted RR, 3.1; 95% CI, 1.0-9.7). Also, 11 of 13 HIV-infected patients who started treatment after a 1-month delay died. Among 173 patients surviving the recommended treatment period, those who completed therapy (66%) had a lower subsequent mortality (20% vs 37%; RR, 0.5; 95% CI, 0.3-0.9).


CONCLUSIONS
Mortality from tuberculosis was high, even among patients without multidrug resistance who were not known to be infected with HIV. Most HIV-seropositive patients with delayed therapy died. Multidrug resistance predicted higher mortality, and treatment completion was associated with improved subsequent patient survival.
Pablos-Méndez
A
A
Division of General Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
Sterling
T R
TR
Frieden
T R
TR
D000293:Adolescent; D000328:Adult; D000368:Aged; D000995:Antitubercular Agents / Q000627:therapeutic use; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000150:complications; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009519:New York City / Q000453:epidemiology; D010349:Patient Compliance; D016016:Proportional Hazards Models; D012042:Registries; D016019:Survival Analysis; D013997:Time Factors; D016312:Treatment Refusal; D014376:Tuberculosis / Q000150:complications / Q000401:mortality* / Q000628:therapy*; D018088:Tuberculosis, Multidrug-Resistant / Q000401:mortality / Q000628:therapy
D000995:Antitubercular Agents