Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru.
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.
Mitnick
Carole
C
Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, Boston, MA 02115, USA. carole_mitnick@hms.harvard.edu
Bayona
Jaime
J
Palacios
Eda
E
Shin
Sonya
S
Furin
Jennifer
J
Alcántara
Felix
F
Sánchez
Epifanio
E
Sarria
Madeleny
M
Becerra
Mercedes
M
Fawzi
Mary C Smith
MC
Kapiga
Saidi
S
Neuberg
Donna
D
Maguire
James H
JH
Kim
Jim Yong
JY
Farmer
Paul
P
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
D000995:Antitubercular Agents