title: Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru.
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.
authors.affiliation: Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, Boston, MA 02115, USA. carole_mitnick@hms.harvard.edu
authors.forename: Carole
authors.initials: C
authors.lastname: Mitnick
authors.forename: Jaime
authors.initials: J
authors.lastname: Bayona
authors.forename: Eda
authors.initials: E
authors.lastname: Palacios
authors.forename: Sonya
authors.initials: S
authors.lastname: Shin
authors.forename: Jennifer
authors.initials: J
authors.lastname: Furin
authors.forename: Felix
authors.initials: F
authors.lastname: Alcántara
authors.forename: Epifanio
authors.initials: E
authors.lastname: Sánchez
authors.forename: Madeleny
authors.initials: M
authors.lastname: Sarria
authors.forename: Mercedes
authors.initials: M
authors.lastname: Becerra
authors.forename: Mary C Smith
authors.initials: MC
authors.lastname: Fawzi
authors.forename: Saidi
authors.initials: S
authors.lastname: Kapiga
authors.forename: Donna
authors.initials: D
authors.lastname: Neuberg
authors.forename: James H
authors.initials: JH
authors.lastname: Maguire
authors.forename: Jim Yong
authors.initials: JY
authors.lastname: Kim
authors.forename: Paul
authors.initials: P
authors.lastname: Farmer
mesh_terms: D000328:Adult; D000553:Ambulatory Care; D000995:Antitubercular Agents / Q000627:therapeutic use*; D003153:Community Health Services; D003906:Developing Countries; D023801:Directly Observed Therapy; D005260:Female; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D010568:Peru; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy* / Q000382:microbiology
chemical_list: D000995:Antitubercular Agents