title: A multi-institutional outbreak of highly drug-resistant tuberculosis: epidemiology and clinical outcomes.
abstract: OBJECTIVE
  To investigate a multi-institutional outbreak of highly resistant tuberculosis and evaluate patient outcome.
  
  
  METHODS
  Epidemiologic investigation of every tuberculosis case reported in New York City.
  
  
  METHODS
  Patients cared for at all public and nonpublic institutions from January 1, 1990, to August 1, 1993 (43 months).
  
  
  METHODS
  We reviewed medical and public health records and conducted clinical, epidemiologic, drug susceptibility, and restriction fragment length polymorphism (RFLP) analyses. A case was defined as tuberculosis in a patient with an isolate resistant to isoniazid, rifampin, ethambutol hydrochloride, and streptomycin (and rifabutin, if sensitivity testing included it), and, if RFLP testing was done, a pattern identical to or closely related to strain W.
  
  
  METHODS
  Patient survival and the conversion of sputum cultures from positive to negative.
  
  
  RESULTS
  Of the 357 patients who met the case definition, 267 had identical or nearly identical RFLP patterns; isolates from the other 90 patients were not available for RFLP testing. Among these 267 patients, 86% were human immunodeficiency virus (HIV)-infected, 7% were HIV-negative, and 7% had unknown HIV status. All-cause mortality was 83%. Epidemiologic linkages were identified for 70% of patients, of whom 96% likely had nosocomially acquired disease at 11 hospitals. Survival was prolonged among patients who received medications to which their isolate was susceptible, especially capreomycin sulfate, and among patients with a CD4+ T-lymphocyte count greater than 0.200 x 10(9)/L (200/microL). Treatment with isoniazid and a fluoroquinolone antibiotic was also independently associated with longer survival.
  
  
  CONCLUSIONS
  This outbreak accounted for nearly one fourth of the cases of multidrug-resistant tuberculosis in the United States during a 43-month period. Most patients had nosocomially acquired disease, were infected with HIV, and unless promptly and appropriately treated, died rapidly. With appropriate directly observed treatment, especially combinations including an injectable medication, even severely immunocompromised patients had culture conversion and prolonged, tuberculosis-free survival.
authors.affiliation: New York City Department of Health, Bureau of Tuberculosis Control, NY 10013, USA.
authors.forename: T R
authors.initials: TR
authors.lastname: Frieden
authors.forename: L F
authors.initials: LF
authors.lastname: Sherman
authors.forename: K L
authors.initials: KL
authors.lastname: Maw
authors.forename: P I
authors.initials: PI
authors.lastname: Fujiwara
authors.forename: J T
authors.initials: JT
authors.lastname: Crawford
authors.forename: B
authors.initials: B
authors.lastname: Nivin
authors.forename: V
authors.initials: V
authors.lastname: Sharp
authors.forename: D
authors.initials: D
authors.lastname: Hewlett
authors.forename: K
authors.initials: K
authors.lastname: Brudney
authors.forename: D
authors.initials: D
authors.lastname: Alland
authors.forename: B N
authors.initials: BN
authors.lastname: Kreisworth
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000995:Antitubercular Agents / Q000494:pharmacology; D015139:Blotting, Southern; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D003428:Cross Infection / Q000150:complications / Q000453:epidemiology* / Q000401:mortality; D004196:Disease Outbreaks; D004977:Ethambutol / Q000494:pharmacology; D005260:Female; D015658:HIV Infections / Q000150:complications; D006801:Humans; D007223:Infant; D007538:Isoniazid / Q000494:pharmacology; D008297:Male; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000187:drug effects* / Q000302:isolation & purification; D009519:New York City / Q000453:epidemiology; D012150:Polymorphism, Restriction Fragment Length; D016016:Proportional Hazards Models; D012293:Rifampin / Q000494:pharmacology; D013183:Sputum / Q000382:microbiology; D013307:Streptomycin / Q000494:pharmacology; D016019:Survival Analysis; D018088:Tuberculosis, Multidrug-Resistant / Q000150:complications / Q000453:epidemiology* / Q000401:mortality
chemical_list: D000995:Antitubercular Agents; D004977:Ethambutol; D007538:Isoniazid; D012293:Rifampin; D013307:Streptomycin