title: Risk factors for mortality among MDR- and XDR-TB patients in a high HIV prevalence setting.
abstract: METHODS
  Recent studies suggest that the prevalence of drug-resistant tuberculosis (TB) in sub-Saharan Africa may be rising. This is of concern, as human immunodeficiency virus (HIV) co-infection in multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB has been associated with exceedingly high mortality rates.
  
  
  OBJECTIVE
  To identify risk factors associated with mortality in MDR- and XDR-TB patients co-infected with HIV in South Africa.
  
  
  METHODS
  Case-control study of patients who died of all causes within 2 years of diagnosis with MDR- or XDR-TB.
  
  
  RESULTS
  Among 123 MDR-TB patients, 78 (63%) died following diagnosis. CD4 count ≤ 50 (HR 4.64, P = 0.01) and 51-200 cells/mm(3) (HR 4.17, P = 0.008) were the strongest independent risk factors for mortality. Among 139 XDR-TB patients, 111 (80%) died. CD4 count ≤ 50 cells/mm(3) (HR 4.46, P = 0.01) and resistance to all six drugs tested (HR 2.54, P = 0.04) were the principal risk factors. Use of antiretroviral therapy (ART) was protective (HR 0.34, P = 0.009).
  
  
  CONCLUSIONS
  Mortality due to MDR- and XDR-TB was associated with greater degree of immunosuppression and drug resistance. Efforts to reduce mortality must focus on preventing the amplification of resistance by strengthening TB treatment programs, as well as reducing the pool of immunosuppressed HIV-infected patients through aggressive HIV testing and ART initiation.
authors.affiliation: Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York 10467, USA. neelgandhi@alumni.williams.edu
authors.forename: N R
authors.initials: NR
authors.lastname: Gandhi
authors.forename: J R
authors.initials: JR
authors.lastname: Andrews
authors.forename: J C M
authors.initials: JC
authors.lastname: Brust
authors.forename: R
authors.initials: R
authors.lastname: Montreuil
authors.forename: D
authors.initials: D
authors.lastname: Weissman
authors.forename: M
authors.initials: M
authors.lastname: Heo
authors.forename: A P
authors.initials: AP
authors.lastname: Moll
authors.forename: G H
authors.initials: GH
authors.lastname: Friedland
authors.forename: N S
authors.initials: NS
authors.lastname: Shah
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality*; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D060085:Coinfection / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality*; D024901:Drug Resistance, Multiple, Bacterial; D054908:Extensively Drug-Resistant Tuberculosis / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality*; D006801:Humans; D008297:Male; D008390:Markov Chains; D009010:Monte Carlo Method; D015995:Prevalence; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D016019:Survival Analysis; D013997:Time Factors; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality*; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality*
chemical_list: D044966:Anti-Retroviral Agents; D000995:Antitubercular Agents