Ambulatory-based standardized therapy for multi-drug resistant tuberculosis: experience from Nepal, 2005-2006.
OBJECTIVE
The aim of this study was to describe treatment outcomes for multi-drug resistant tuberculosis (MDR-TB) outpatients on a standardized regimen in Nepal.


METHODS
Data on pulmonary MDR-TB patients enrolled for treatment in the Green Light Committee-approved National Programme between 15 September 2005 and 15 September 2006 were studied. Standardized regimen was used (8Z-Km-Ofx-Eto-Cs/16Z-Ofx-Eto-Cs) for a maximum of 32 months and follow-up was by smear and culture. Drug susceptibility testing (DST) results were not used to modify the treatment regimen. MDR-TB therapy was delivered in outpatient facilities for the whole course of treatment. Multivariable analysis was used to explain bacteriological cure as a function of sex, age, initial body weight, history of previous treatment and the region of report.


RESULTS
In the first 12-months, 175 laboratory-confirmed MDR-TB cases (62% males) had outcomes reported. Most cases had failed a Category 2 first-line regimen (87%) or a Category 1 regimen (6%), 2% were previously untreated contacts of MDR-TB cases and 5% were unspecified. Cure was reported among 70% of patients (range 38%-93% by Region), 8% died, 5% failed treatment, and 17% defaulted. Unfavorable outcomes were not correlated to the number of resistant drugs at baseline DST. Cases who died had a lower mean body weight than those surviving (40.3 kg vs 47.2 kg, p<0.05). Default was significantly higher in two regions [Eastern OR = 6.2; 95%CL2.0-18.9; Far West OR = 5.0; 95%CL1.0-24.3]. At logistic regression, cure was inversely associated with body weight <36 kg [Adj.OR = 0.1; 95%CL0.0-0.3; ref. 55-75 kg] and treatment in the Eastern region [Adj.OR = 0.1; 95%CL0.0-0.4; ref. Central region].


CONCLUSIONS
The implementation of an ambulatory-based treatment programme for MDR-TB based on a fully standardized regimen can yield high cure rates even in resource-limited settings. The determinants of unfavorable outcome should be investigated thoroughly to maximize likelihood of successful treatment.
Malla
Pushpa
P
National Tuberculosis Centre, Ministry of Health and Population, Kathmandu, Nepal.
Kanitz
Elisabeth Eva
EE
Akhtar
Mohammad
M
Falzon
Dennis
D
Feldmann
Knut
K
Gunneberg
Christian
C
Jha
Shyam Sundar
SS
Maharjan
Bhagwan
B
Prasai
Mohan Kumar
MK
Shrestha
Bhabana
B
Verma
Sharat Chandra
SC
Zignol
Matteo
M
D000328:Adult; D000554:Ambulatory Care Facilities; D000995:Antitubercular Agents / Q000009:adverse effects / Q000627:therapeutic use*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009390:Nepal; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy* / Q000401:mortality; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy* / Q000401:mortality; D055815:Young Adult
D000995:Antitubercular Agents