title: Survival from XDR-TB is associated with modifiable clinical characteristics in rural South Africa.
abstract: BACKGROUND
  Drug-resistant tuberculosis (TB) is a major threat to global public health. Patients with extensively drug-resistant TB (XDR-TB), particularly those with HIV-coinfection, experience high and accelerated mortality with limited available interventions. To determine modifiable factors associated with survival, we evaluated XDR-TB patients from a community-based hospital in rural South Africa where a large number of XDR-TB cases were first detected.
  
  
  RESULTS
  A retrospective case control study was conducted of XDR-TB patients diagnosed from 2005-2008. Survivors, those alive at 180 days from diagnostic sputum collection date, were compared with controls who died within 180 days. Clinical, laboratory and microbiological correlates of survival were assessed in 69 survivors (median survival 565 days [IQR 384-774] and 73 non-survivors (median survival 34 days [IQR 18-90]). Among 129 HIV+ patients, multivariate analyses of modifiable factors demonstrated that negative AFB smear (AOR 8.4, CI 1.84-38.21), a lower laboratory index of routine laboratory findings (AOR 0.48, CI 0.22-1.02), CD4>200 cells/mm(3) (AOR 11.53, 1.1-119.32), and receipt of antiretroviral therapy (AOR 20.9, CI 1.16-376.83) were independently associated with survival from XDR-TB.
  
  
  CONCLUSIONS
  Survival from XDR-TB with HIV-coinfection is associated with less advanced stages of both diseases at time of diagnosis, absence of laboratory markers indicative of multiorgan dysfunction, and provision of antiretroviral therapy. Survival can be increased by addressing these modifiable risk factors through policy changes and improved clinical management. Health planners and clinicians should develop programmes focusing on earlier case finding and integration of HIV and drug-resistant TB diagnostic, therapeutic, and preventive activities.
authors.affiliation: Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University, School of Medicine New Haven, Connecticut, United States of America. sheela.shenoi@yale.edu
authors.forename: Sheela V
authors.initials: SV
authors.lastname: Shenoi
authors.forename: Ralph P
authors.initials: RP
authors.lastname: Brooks
authors.forename: Russell
authors.initials: R
authors.lastname: Barbour
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
authors.forename: Daniel
authors.initials: D
authors.lastname: Zelterman
authors.forename: Anthony P
authors.initials: AP
authors.lastname: Moll
authors.forename: Iqbal
authors.initials: I
authors.lastname: Master
authors.forename: Theo L
authors.initials: TL
authors.lastname: van der Merwe
authors.forename: Gerald H
authors.initials: GH
authors.lastname: Friedland
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D000995:Antitubercular Agents / Q000627:therapeutic use; D016022:Case-Control Studies; D060085:Coinfection / Q000188:drug therapy / Q000401:mortality; D054908:Extensively Drug-Resistant Tuberculosis / Q000188:drug therapy / Q000401:mortality*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013019:South Africa
chemical_list: D000995:Antitubercular Agents