title: High mortality in adults hospitalized for active tuberculosis in a low HIV prevalence setting.
abstract: BACKGROUND
  This study aims to evaluate the outcomes of adults hospitalized for tuberculosis in a higher-income region with low HIV prevalence.
  
  
  METHODS
  A retrospective cohort study was conducted on all adults hospitalized for pulmonary and/or extrapulmonary tuberculosis in an acute-care hospital in Hong Kong during a two-year period. Microscopy and solid-medium culture were routinely performed. The diagnosis of tuberculosis was made by: (1) positive culture of M. tuberculosis, (2) positive M. tuberculosis PCR result, (3) histology findings of tuberculosis infection, and/or (4) typical clinico-radiological manifestations of tuberculosis which resolved after anti-TB treatment, in the absence of alternative diagnoses. Time to treatment ('early', started during initial admission; 'late', subsequent periods), reasons for delay, and short- and long-term survival were analyzed.
  
  
  RESULTS
  Altogether 349 patients were studied [median(IQR) age 62(48-77) years; non-HIV immunocompromised conditions 36.7%; HIV/AIDS 2.0%]. 57.9%, 16.3%, and 25.8% had pulmonary, extrapulmonary, and pulmonary-extrapulmonary tuberculosis respectively. 58.2% was smear-negative; 0.6% multidrug-resistant. 43.4% developed hypoxemia. Crude 90-day and 1-year all-cause mortality was 13.8% and 24.1% respectively. 57.6% and 35.8% received 'early' and 'late' treatment respectively, latter mostly culture-guided [median(IQR) intervals, 5(3-9) vs. 43(25-61) days]. Diagnosis was unknown before death in 6.6%. Smear-negativity, malignancy, chronic lung diseases, and prior exposure to fluoroquinolones (adjusted-OR 10.6, 95%CI 1.3-85.2) delayed diagnosis of tuberculosis. Failure to receive 'early' treatment independently predicted higher mortality (Cox-model, adjusted-HR 1.8, 95%CI 1.1-3.0).
  
  
  CONCLUSIONS
  Mortality of hospitalized tuberculosis patients is high. Newer approaches incorporating methods for rapid diagnosis and initiation of anti-tuberculous treatment are urgently required to improve outcomes.
authors.affiliation: Department of Medicine and Therapeutics, Division of Infectious Diseases, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China.
authors.forename: Grace
authors.initials: G
authors.lastname: Lui
authors.affiliation: Department of Medicine and Therapeutics, Division of Infectious Diseases, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China.
authors.forename: Rity Y K
authors.initials: RY
authors.lastname: Wong
authors.affiliation: Faculty of Medicine, University of Sheffield, Sheffield, United Kingdom.
authors.forename: Florence
authors.initials: F
authors.lastname: Li
authors.affiliation: Department of Microbiology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China.
authors.forename: May K P
authors.initials: MK
authors.lastname: Lee
authors.affiliation: Department of Microbiology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China.
authors.forename: Raymond W M
authors.initials: RW
authors.lastname: Lai
authors.affiliation: Department of Medicine and Therapeutics, Division of Infectious Diseases, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China.
authors.forename: Timothy C M
authors.initials: TC
authors.lastname: Li
authors.affiliation: Stanley Ho Centre for Emerging Infectious Diseases, Chinese University of Hong Kong, Hong Kong SAR, China.
authors.forename: Joseph K M
authors.initials: JK
authors.lastname: Kam
authors.affiliation: Department of Medicine and Therapeutics, Division of Infectious Diseases, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China; Stanley Ho Centre for Emerging Infectious Diseases, Chinese University of Hong Kong, Hong Kong SAR, China.
authors.forename: Nelson
authors.initials: N
authors.lastname: Lee
mesh_terms: D000368:Aged; D000995:Antitubercular Agents / Q000627:therapeutic use; D060085:Coinfection; D057210:Delayed Diagnosis; D005260:Female; D024841:Fluoroquinolones / Q000627:therapeutic use; D006678:HIV; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality* / Q000821:virology; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D012189:Retrospective Studies; D016019:Survival Analysis; D020306:Tuberculosis, Central Nervous System / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality*; D014388:Tuberculosis, Lymph Node / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality*; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality*; D014396:Tuberculosis, Pleural / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality*; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality*; D014401:Tuberculosis, Urogenital / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality*
chemical_list: D000995:Antitubercular Agents; D024841:Fluoroquinolones