Why do our patients die of active tuberculosis in the era of effective therapy?

Time to diagnosis and treatment of pulmonary tuberculosis in indigenous peoples: a systematic review

BACKGROUND

Time to diagnosis and treatment is a major factor in determining the likelihood of tuberculosis (TB) transmission and is an important area of intervention to reduce the reservoir of TB infection and prevent disease and mortality. Although Indigenous peoples experience an elevated incidence of TB, prior systematic reviews have not focused on this group. We summarize and report findings related to time to diagnosis and treatment of pulmonary TB (PTB) among Indigenous peoples, globally.

METHODS

A Systematic review was performed using Ovid and PubMed databases. Articles or abstracts estimating time to diagnosis, or treatment of PTB among Indigenous peoples were included with no restriction on sample size with publication dates restricted up to 2019. Studies that focused on outbreaks, solely extrapulmonary TB alone in non-Indigenous populations were excluded. Literature was assessed using the Hawker checklist. Registration Protocol (PROSPERO): CRD42018102463.

RESULTS

Twenty-four studies were selected after initial assessment of 2021 records. These included Indigenous groups from five of six geographical regions outlined by the World Health Organization (all except the European Region). The range of time to treatment (24-240 days), and patient delay (20 days-2.5 years) were highly variable across studies and, in at least 60% of the studies, longer in Indigenous compared to non-Indigenous peoples. Risk factors associated with longer patient delays included poor awareness of TB, type of health provider first seen, and self-treatment.

CONCLUSION

Time to diagnosis and treatment estimates for Indigenous peoples are generally within previously reported ranges from other systematic reviews focusing on the general population. However among literature examined in this systematic review that stratified by Indigenous and non-Indigenous peoples, patient delay and time to treatment were longer compared to non-Indigenous populations in over half of the studies. Studies included were sparse and highlight an overall gap in literature important to interrupting transmission and preventing new TB cases among Indigenous peoples. Although, risk factors unique to Indigenous populations were not identified, further investigation is needed as social determinants of health among studies conducted in medium and high incidence countries may be shared across both population groups. Trial registration N/a.

Sudden Death from Cardiopulmonary Arrest on Arrival of a Patient with Pulmonary Tuberculosis: A Case Diagnosed by Postmortem CT and Autopsy

Sudden death due to massive hemoptysis during management of tuberculosis occurs in a considerable number of patients. However, when massive airway hemorrhage occurs in a patient in whom tuberculosis has not been confirmed and a blood is not apparent externally on the face/body, it is difficult to immediately identify the cause of death as airway obstruction by tuberculous bleeding in the airway. We encountered an 83-year-old Japanese woman with her medical history included treatment of tuberculosis in her 20s who was in cardiopulmonary arrest on arrival (CPAOA), and the cause of sudden death could not initially be identified. Postmortem CT (PMCT) and autopsy revealed that the cause of sudden death was airway obstruction/asphyxia by tuberculous massive airway hemorrhage. Identification of the cause of death facilitated a subsequent active contact investigation and led to prevention of secondary tuberculosis infection.

Pulmonary tuberculosis: Diagnostic delay in Tunisia

OBJECTIVE

Early diagnosis and prompt effective therapy are crucial to fight against tuberculosis (TB), particularly in regions with a high prevalence. We aimed to evaluate TB diagnostic delays and identify the associated risk factors.

METHODS

We conducted a survey in various health facilities in Tunisia between March 24th and October 30th, 2014. We included all patients aged ≥ 18 years who presented with pulmonary TB (PTB) and who had been initiated on an anti-TB treatment. We evaluated the time between respiratory symptom onset and treatment initiation. Treatment delays were divided into three categories: delays due to the patient, to the healthcare system, and overall delays.

RESULTS

We included 352 patients in the study (242 men and 110 women). The mean age was 42.2 years±17.7. The median time from symptom onset to treatment initiation was 52.56 days. Patient delays were longer for men, for patients presenting with alcohol dependence, and for patients who already knew they were sick. Healthcare system delays were associated with older age, female patients, patients consulting a private physician, and outpatients.

CONCLUSION

TB symptoms should be better explained to the population and healthcare professionals should be better trained to both reduce such delays and initiate treatment as early as possible.

Tuberculosis mortality: patient characteristics and causes

BACKGROUND

In the antibiotic era, tuberculosis (TB) still causes a substantial number of mortalities. We aimed to identify the causes and risks of death among TB patients.

METHODS

Medical records of mortality cases of culture-proven TB diagnosed during 2003-2007 were reviewed. All TB deaths were classified into 2 groups (TB-related and non-TB-related), based on the underlying cause of death.

RESULTS

During the study period, 2016 cases (male: 71.1%) of culture-proven TB were identified. The mean age was 59.3 (range: 0.3-96) years. The overall mortality rate was 12.3% (249 cases) and the mean age at death was 74 years; 17.3% (43 cases) of all TB deaths were TB-related. Most of the TB-related deaths occurred early (median survival: 20 days), and the patient died of septic shock. Malignancy, liver cirrhosis, renal failure, and miliary and pneumonic radiographic patterns were all independent predictors for all TB deaths. Cavitary, miliary and pneumonic radiographic patterns were all significant predictive factors for TB-related death. Extrapulmonary involvement and liver cirrhosis were also factors contributing to TB-related death.

CONCLUSIONS

The majority of TB deaths were ascribed to non-TB-related causes. Managing TB as well as underlying comorbidities in a multidisciplinary approach is essential to improve the outcome of patients in an aging population. However, the clinical manifestations of patients with TB-related death vary; many progressed to fulminant septic shock requiring timely recognition with prompt treatment to prevent early death.

Patient and health system delay among patients with pulmonary tuberculosis in Beira city, Mozambique

BACKGROUND

TB control is based on the rapid identification of cases and their effective treatment. However, many studies have shown that there are important delays in diagnosis and treatment of patients with TB. The purpose of this study was to assess the prevalence of and identify risk factors associated with patient delay and health system delay among newly diagnosed patients with pulmonary TB.

METHODS

A cross sectional study was carried out in Beira city, Mozambique between September 2009 and February 2010. Patients in the first month of treatment were consecutively selected to this study if they had a diagnosis of pulmonary TB, had no history of previous TB treatment, and were 18 years or older and provided informed consent. Data was obtained through a questionnaire administered to the patients and from patients' files.

RESULTS

Among the 622 patients included in the study the median age was 32 years (interquartile range, 26-40) and 272 (43.7%) were females. The median total delay, patient delay and health system delay was 150 days (interquartile range, 91-240), 61 days (28-113) and 62 days (37-120), respectively. The contribution of patient delay and health system delay to total delay was similar. Farming, visiting first a traditional healer, low TB knowledge and coexistence of a chronic disease were associated with increased patient delay. More than two visits to a health facility, farming and coexistence of a chronic disease were associated with increased health system delay.

CONCLUSIONS

This study revealed a long total delay with a similar contribution of patient delay and health system delay. To reduce the total delay in this setting we need a combination of interventions to encourage patients to seek appropriate health care earlier and to expedite TB diagnosis within the health care system.

Factors associated with death among HIV-uninfected TB patients in Thailand, 2004-2006

OBJECTIVES

In countries with both TB and human immunodeficiency virus (HIV) epidemics, HIV is known to be the most powerful risk factor for death during tuberculosis (TB) treatment. Few recent studies have evaluated risk factors for death among HIV-uninfected TB patients in these countries. We analysed data from a multi-province demonstration project in Thailand to answer this question.

METHOD

We prospectively collected data from HIV-uninfected TB patients treated for TB in four provinces and the national infectious diseases hospital in Thailand from 2004-2006. Standard WHO definitions were used to classify treatment outcomes. We used log-binomial multivariate regression to calculate adjusted relative risk (aRR) and 95% confidence intervals (CI) for factors associated with death.

RESULTS

Of 5318 cases, 441 (8%) died during TB treatment. The mean age was 47 years (range 8 months-97 years). Multidrug-resistant (MDR)-TB was diagnosed in 62 (1%). In multivariate analysis, patients older than 44 years were significantly more likely to die than patients aged 15-44 years [age 45-64, aRR 2.9 (CI 2.2-3.8)] [age > 64 years, aRR 5.0 (CI 3.9-6.6)]. Other independent risk factors for death included Thai nationality [aRR 3.9 (CI 1.6-9.5)], MDR-TB [aRR 2.8 (CI 1.7-4.8)], not being married [aRR 1.4 (CI 1.2-1.7)], and living in Chiang Rai province [aRR 2.7 (CI 1.7-4.4)].

CONCLUSIONS

The death rate was high among HIV-uninfected TB patients in Thailand. Efforts to improve TB diagnosis and treatment in the elderly and to improve MDR-TB treatment may help reduce mortality.

Profile of tuberculosis patients progressing to death, city of São Paulo, Brazil, 2002

OBJECTIVE

To profile adult patients dying of tuberculosis in the city of São Paulo with respect to biological, environmental and institutional factors.

METHODS

Descriptive study covering all tuberculosis deaths (N=416) among individuals aged over 15 years in 2002. Data were obtained from hospital records, the local Mortality Information System, Coroner's Service, and tuberculosis Surveillance System. The estimates of relative risk and 95% confidence intervals (95% CI) were based on the reference group, i.e., females aged 15 to 29 years, originally from the State of São Paulo (Brazil). A comparative analysis was conducted using Pearson's chi-square test and Fisher's exact test for categorical variables and Kruskal-Wallis test for continuous variables.

RESULTS

Of all tuberculosis deaths identified, 78% had pulmonary form. Tuberculosis diagnosis was made after death in 30% and in primary health care units in 14%. Of them, 44% had not started treatment; 49% were not notified; and 76% were men. The median age was 51 years; 52% had up to four years of schooling; 4% were probably living in the streets. Mortality rate increased with age; it was 5.0/100,000 for the entire city, ranging between zero to 35 according to the district. Previous treatment was reported for 82 out of 232 patients, and of them, 41 defaulted treatment. Diabetes (16%), chronic obstructive pulmonary disease (19%), HIV infection (11%), smoking (71%), and alcohol abuse (64%) were also reported.

CONCLUSIONS

Adult males over 50, migrants and living in lower Human Development Index districts were more likely to die of tuberculosis. Low schooling and comorbidities are relevant characteristics. Low involvement of primary care units in tuberculosis diagnosis and high underreporting of cases were also seen.

[Analysis of the treatment of pulmonary tuberculosis in elderly patients at a university hospital in Rio de Janeiro, Brazil]

OBJECTIVE

To describe the clinical and therapeutic aspects of pulmonary tuberculosis and compare the adverse effects of the treatment and its outcome in elderly and nonelderly patients.

METHODS

This was a case-control study of 117 elderly individuals (over the age of 60 years) and 464 nonelderly individuals (aged 15-49 years). All subjects presented pulmonary tuberculosis that had been diagnosed and treated at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro between 1980 and 1996.

RESULTS

In the elderly group, pulmonary tuberculosis was found to be correlated with diabetes (OR = 3.98; 95% CI = 2.07-7.65; p = 0.001), lung disease (OR = 7.24; 95% CI = 3.64-14.46; p = 0.001) and heart disease (OR = 5.86; 95% CI = 2.88-11.95; p = 0.001). Smoking (OR = 2.07; 95% CI = 1.26-3.42; p = 0.002) and alcohol abuse (OR = 1.63; 95% CI = 1.01-2.68; p = 0.041) were also more common in the elderly group. In the elderly group, the treatment more frequently resulted in adverse reactions (OR = 1.62; 95% CI = 1.04-2.54; p = 0.024), especially gastrointestinal reactions (OR = 1.64; 95% CI = 1.01-2.77; p = 0.047), and treatment efficacy was lower: cure rate, 51%; mortality rate, 24%. Treatment adherence was low (approximately 77%) in both groups.

CONCLUSIONS

In the elderly group, adverse reactions were more common, treatment outcomes were less favorable, there was a greater frequency of clinical complications and deaths related to drug toxicity, and the prevalence of concomitant diseases was higher.

Factors associated with treatment failure, dropout, and death in a cohort of tuberculosis patients in Recife, Pernambuco State, Brazil

A cohort of cases initiating tuberculosis treatment from May 2001 to July 2003 was followed in Recife, Pernambuco State, Brazil, to investigate biological, clinical, social, lifestyle, and healthcare access factors associated with three negative tuberculosis treatment outcomes (treatment failure, dropout, and death) separately and as a group. Treatment failure was associated with treatment delay, illiteracy, and alcohol consumption. Factors associated with dropout were age, prior TB treatment, and illiteracy. Death was associated with age, treatment delay, HIV co-infection, and head of family's income. Main factors associated with negative treatment outcomes as a whole were age, HIV co-infection, illiteracy, alcoholism, and prior TB treatment. We suggest the following strategies to increase cure rates: further training of the Family Health Program personnel in TB control, awareness-raising on the need to tailor their activities to special care for cases (e.g., literacy training); targeting use of directly observed therapy for higher risk groups; establishment of a flexible referral scheme to handle technical and psychosocial problems, including alcoholism; and increased collaboration with the HIV/AIDS program.

[Tuberculosis in the autopsy. Clinical and pathological study: an analysis of 92 cases of active tuberculosis found in 2,180 autopsies]

BACKGROUND AND OBJECTIVE

Tuberculosis is an infectious disease currently having great importance in the daily clinical practice in Spain. Some cases of active tuberculosis are not identified until after the patient had died and an autopsy has been performed. This study has analyzed the clinical and pathological characteristics of patients diagnosed with active tuberculosis in the autopsy.

MATERIAL AND METHOD

We reviewed all the autopsies performed in the University Hospital 12 de Octubre of Madrid between 1974 and 2002. The autopsy reports and clinical records were examined in those cases in which active tuberculosis was found.

RESULTS

We found 92 cases of active tuberculosis, 57% corresponding to men. Mean age of this group was 64 years. A total of 20% of the patients died within 48 hours after admission. Predisposing factors were identified in 90% of the cases. Dyspnea (24% of cases) and wasting syndrome (23%) were the main symptoms that motivated patients to request medical attention. Up to 30% of cases had normal chest X-ray. Tuberculosis was suspected in only 46% of patients before death. Principal cause of death was tuberculosis in 61% of patients, 52% of patients had pulmonary tuberculosis, 28% suffered from miliary tuberculosis and 20% from extra-pulmonary tuberculosis. The lungs were the most frequently affected organ. Epithelioid granulomas were found in all patients.

CONCLUSIONS

Tuberculosis is an uncommon finding in the autopsy as the cause of death. The presence of unspecific symptomatology, insufficient cost-effectiveness of the diagnostic tests and precocious death, are identified as the most frequent causes of undiagnosed tuberculosis.

Is alcohol use associated with cavitary disease in tuberculosis?

BACKGROUND

Alcohol mediates detrimental alterations in the immune response to Mycobacterium tuberculosis. The association between quantity and frequency of alcohol use and the prevalence of cavitary disease in tuberculosis (TB) has not been analyzed. To investigate the relationship of alcohol use and the prevalence of cavitary disease in a 6-year population-based data set of individuals with TB.

METHODS

We assessed quantity and frequency of alcohol use (daily alcohol use, years of alcohol use, and lifetime alcohol use) with a standardized questionnaire. The study group consisted of 1,250 patients analyzed for cavitary disease (HIV sero-negative subjects that were 18 years or older). Significant covariates for cavitary disease were entered into multiple logistic regression models.

RESULTS

Although daily alcohol use, years of alcohol use, and alcohol use 30 days or 6 months before symptom onset were significant predictors of cavitary disease in univariate analysis, no independent associations were found between alcohol use and cavitary disease in the multivariate analysis. Only diabetes mellitus was independently associated with cavitary disease at any level or frequency of alcohol use.

CONCLUSION

Alcohol use is not independently associated with increased prevalence of cavitary disease in adult patients with TB.

Determinants of health system delay among confirmed tuberculosis cases in Spain

BACKGROUND

Health system delay (HSD) is an important issue in tuberculosis (TB) control. This report investigates HSD and associated factors in a cohort of Spanish culture-confirmed TB patients.

METHODS

Data were collected from clinical records. Using logistic regression with two different cut-off points to define HSD (median and 75th percentile), adjusted odds ratios were used to estimate the association between HSD and different variables.

RESULTS

A total of 5184 culture-confirmed TB cases were included. Median and 75th percentile HSD were 6 and 25 days respectively. HSD significantly greater than the median was associated with: age >44 years, past or present intravenous drug use, diagnosis at a primary-care centre, prior preventive therapy, positive histology, request for drug-sensitivity testing, presence of silicosis or neoplasia in addition to TB, presence of non-TB related symptoms, and gastrointestinal site. HSD greater than the 75th percentile was related to the same variables, with the exception of diagnosis at a primary-care centre, positive histology, silicosis, non-TB-related symptoms and gastrointestinal site, for which the association disappeared; in contrast, an association with female gender emerged.

CONCLUSION

Despite free health care being universally available in Spain, there are some groups of TB patients whose treatment is unduly delayed.

Treatment outcome of new culture positive pulmonary tuberculosis in Norway

Background

The key elements in tuberculosis (TB) control are to cure the individual patient, interrupt transmission of TB to others and prevent the tubercle bacilli from becoming drug resistant. Incomplete treatment may result in excretion of bacteria that may also acquire drug resistance and cause increased morbidity and mortality. Treatment outcome results serves as a tool to control the quality of TB treatment provided by the health care system. The aims of this study were to evaluate the treatment outcome for new cases of culture positive pulmonary TB registered in Norway during the period 1996–2002 and to identify factors associated with non-successful treatment.

Methods

This was a register-based cohort study. Treatment outcome was assessed according to sex, birthplace, age group, isoniazid (INH) susceptibility, mode of detection and treatment periods (1996–1997, 1998–1999 and 2000–2002). Logistic regression was also used to estimate the odds ratio for treatment success vs. non-success with 95% confidence interval (CI), taking the above variables into account.

Results

Among the 655 patients included, the total treatment success rate was 83% (95% CI 80%–86%). The success rates for those born in Norway and abroad were 79% (95% CI 74%–84%) and 86% (95% CI 83%–89%) respectively. There was no difference in success rates by sex and treatment periods. Twenty-two patients (3%) defaulted treatment, 58 (9%) died and 26 (4%) transferred out. The default rate was higher among foreign-born and male patients, whereas almost all who died were born in Norway. The majority of the transferred out group left the country, but seven were expelled from the country. In the multivariate analysis, only high age and initial INH resistance remained as significant risk factors for non-successful treatment.

Conclusion

Although the TB treatment success rate in Norway has increased compared to previous studies and although it has reached a reasonable target for treatment outcome in low-incidence countries, the total success rate for 1996–2002 was still slightly below the WHO target of success rate of 85%. Early diagnosis of TB in elderly patients to reduce the death rate, abstaining from expulsion of patients on treatment and further measures to prevent default could improve the success rate further.

Perfil de mortalidade de pacientes com tuberculose relacionada à comorbidade tuberculose-Aids

OBJETIVO: Analisar o perfil dos óbitos entre pacientes com tuberculose, e descrever a co-infecção tuberculose-Aids e a causa básica de morte nas coortes anuais. MÉTODOS: Foi realizado estudo descritivo dos indivíduos residentes na cidade de Campinas, SP, que foram a óbito durante o tratamento para tuberculose e também dos pacientes notificados após o óbito, mesmo sem ter iniciado o tratamento. As informações foram obtidas do Banco de Dados em Tuberculose /Universidade Estadual de Campinas (Unicamp) e do Banco de Óbitos da Secretaria Municipal de Saúde/Unicamp. Para análise estatística utilizou-se o software Epi Info versão 6. Os óbitos foram agrupados em dois períodos (1993-1996 e 1997-2000) e as proporções, comparadas. RESULTADOS: Foram notificados 4.680 pacientes, totalizando 737 óbitos, com coeficiente de letalidade de 18,1%, de 1993 a 1996, e 13,5%, de 1997 a 2000. Em 78 óbitos (10,6%) a notificação foi no post mortem e não chegou a ser instituído tratamento específico. Verificou-se predomínio do sexo masculino (71,3%) nos dois períodos estudados. A comorbidade tuberculose-Aids esteve presente em 55% dos óbitos. O perfil etário diferiu segundo a presença ou não da Aids: em ambos os períodos, a mediana da idade nos óbitos com Aids esteve na faixa de 30 a 39 e entre 50 e 59 naqueles sem Aids. Os pacientes que nunca haviam sido tratados de tuberculose representaram 81,3% CONCLUSÕES: Destaca-se entre os achados a marcante redução do número de óbitos, a partir de 1997, que pode estar relacionada com a utilização da terapia anti-retroviral (HAART) para Aids.

Tuberculosis en la Ciudad de la Habana, 1995-1999

OBJETIVO: La tuberculosis es un importante problema mundial de salud que recibe una atención priorizada del Sistema de Salud Cubano. Lo objetivo del trabajo es describir el comportamiento de los indicadores del Programa de Control de Tuberculosis cubano. MÉTODOS: A partir de una revisión de los documentos de la vigilancia de la tuberculosis en los registros del Centro Provincial de Higiene y Epidemiología se expone la infraestructura sanitaria, las estrategias del Programa de Control en la ciudad, se describen las tasas de incidencia, indicadores de localización, diagnóstico y manejo de casos. RESULTADOS: Se hallaron 8 sintomáticos respiratorios por cada mil consultantes de medicina general; la tasa de incidencia de tunerculosis en todas sus formas descendió de 16,4 (1995) a 12,0x105 habitantes (1999); la tuberculosis pulmonar descendió de 15,1 a 10,45 habitantes mientras la tuberculosis extrapulmonar ascendió de 1,3 a 1,6 x 105 habitantes, en igual período. Del total de los casos nuevos, el 40-50% fueron identificados en los policlínicos, el 67% fueron diagnosticados por baciloscopías, el 15,2% por cultivos, el 13.8% sólo por evidencias clínicas y radiológicas; el 0,9% y el 1,5%, respectivamente, fueron diagnosticados por biopsia o hallazgos de necropsia. Los grupos de 15-64 años incrementaron su incidencia en 1996-1997 y disminuyeron en 1998-1999; los casos >64 años de edad disminuyeron progresivamente de 1995 a 1999; en general, la tasa de incidencia de casos disminuyó. La demora promedio entre primeros síntomas y diagnóstico mejoró de 42 días en 1995 a 28,6 en 1999. CONCLUSIONES: La reversión de la tendencia de la notificación de casos nuevos parece haberse detenido en 1996. La situación de los indicadores de tuberculosis revelan cambios satisfactorios en el período analizado.

[Pulmonary symptomatic tuberculosis' diagnostic delay study]

OBJECTIVE

To study symptomatic pulmonary tuberculosis (PTB) diagnostic delay.

PATIENTS AND METHODS

Prospective study of new symptomatic PTB cases (aged > or = 15 years) by structured interview with the patients and their families. The main variables analyzed were patient's delay (PD), doctor's delay (DD), diagnostic process delay (DPD), health care system delay (HCSD) and total delay between the onset of symptoms and start of treatment (TD). Univariate and multivariate statistical analyses were performed for each component of delay.

RESULTS

Two hundred eighty-seven patients were studied. The mean delays in days standard deviations were TD 81.8 77.3; PD 43.3 55.7; DD 28.4 59.6; DPD 10.0 17.7, and HCSD 38.5 62.5.

CONCLUSIONS

Patients are responsible for 50% of excess delay in diagnosing symptomatic PTB. Patients in the health care system experienced diagnostic delays over 60 days in 18.5% of cases, doctors being responsible for 75% of the diagnostic delay attributable to the system.

Survival of patients with pulmonary tuberculosis: clinical and molecular epidemiologic factors

Using restriction fragment-length polymorphism data, we conducted a retrospective cohort study of 139 adult patients with pulmonary tuberculosis to investigate the clinical impact of Mycobacterium tuberculosis infection with a clustered isolate. The cumulative all-cause mortality rate during treatment was 21%. Patients with clustered DNA fingerprint patterns had a reduced risk of death, compared with patients with unique patterns (hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.2-1.1), but this finding was confounded by age (adjusted HR, 0.8; 95% CI, 0.4-1.8). After adjustment for age, the strongest predictors of death were such underlying illnesses as diabetes mellitus, renal failure, chronic obstructive pulmonary disease, and human immunodeficiency virus infection. We conclude that comorbidity and immunosuppression are important predictors of survival for patients with pulmonary tuberculosis in an inner-city cohort. Recently transmitted infection, as determined by use of DNA fingerprinting to classify patients' isolates as being either clustered or unique, was not independently associated with death.

Utility of rifampin blood levels in the treatment and follow-up of active pulmonary tuberculosis in patients who were slow to respond to routine directly observed therapy

STUDY OBJECTIVE

The standard daily dose of rifampin in directly observed treatment of Mycobacterium tuberculosis (TB) is 600 mg, taken orally. The purpose of this study was to assess the efficacy of standard dose rifampin therapy in patients who were slow to respond to routine directly observed therapy (DOT).

METHODS

Patients with non-drug-resistant pulmonary TB who were receiving 600 mg of oral rifampin by DOT were eligible for inclusion. Patients were deemed slow to respond if their sputum smears and cultures remained positive for M tuberculosis and if the patient's condition did not improve clinically or radiographically after 3 months of treatment. Serum rifampin levels were ascertained to determine the adequacy of the standard rifampin dosing. Patients with subtherapeutic blood levels had their rifampin dose increased to 900 mg, and rifampin levels were repeated. Rifampin dosage was increased again if blood levels were still subtherapeutic. No antitubercular medications were added to the treatment regimen. The total weekly dose of the other standard treatment drugs was not increased.

RESULTS

Of 124 new patients with active pulmonary TB, 6 patients were identified as slow to respond to the standard antitubercular DOT. All six patients had subtherapeutic serum rifampin levels. All six patients responded clinically, radiographically, and mycobacteriologically after an increase in rifampin dosage to reach target drug blood level.

CONCLUSIONS

Standard dosing with rifampin resulted in a poor clinical response and subtherapeutic serum levels in six patients. Increasing the dosage of rifampin improved the outcome without additional side effects. In TB patients who are slow to respond to standard treatment, an inadequate dose of rifampin should be suspected. Current antituberculer drug administration does not include adjusted dosage for rifampin.

Tuberculosis and sudden death: a case report and review

Although deaths from tuberculosis (TB) are increasing, TB-related sudden death (TBRSD) is rarely reported in the literature. We present a case report of fatal pulmonary TB with extrapulmonary extension in a patient infected with the human immunodeficiency virus (HIV) and a review of published reports of TBRSD in MEDLINE (1966 to October 2000). Forty-six cases of TBRSD were reported. The most common cause of TBRSD was tuberculous bronchopneumonia in 30 (64%) patients, followed by hemoptysis in 14 (30%) patients. Tuberculous myocarditis and isolated TB of the adrenal glands are seldom causes of TBRSD. The early detection of TB, use of directly observed therapy, and individualization of treatment can be helpful in decreasing the incidence of TBRSD.

The impact of comorbidity on mortality following in-hospital diagnosis of tuberculosis

STUDY OBJECTIVES

Despite the availability of curative chemotherapy, mortality remains high among patients hospitalized for tuberculosis. Although the elevated mortality rate is often attributed to the presence of multidrug resistant tuberculosis (MDRTB) or concomitant infection with the HIV, other factors must be contributory, especially among the HIV-negative population. Therefore, we performed a study to define the factors associated with mortality following the in-hospital diagnosis of tuberculosis in a region with low levels of MDRTB and coinfection with HIV.

DESIGN

Retrospective cohort study.

SETTING

The eight hospitals in the Barnes-Jewish-Christian (BJC) Health System, which is a network of community and tertiary-care level facilities serving the St. Louis, MO, metropolitan area.

PATIENTS

All 203 patients hospitalized with culture-positive tuberculosis at one of the BJC system hospitals between 1988 and 1996.

INTERVENTIONS

Follow-up information was obtained by telephone interview and review of medical and public health records. Death was verified through a search of the death certificate registry of Missouri and the records of the Social Security Administration. Mortality was defined as death from any cause during the 14 months following the initial date of hospitalization.

MEASUREMENTS AND RESULTS

The cumulative all-cause mortality rate for this cohort was 28.1%. The incidence of HIV positivity was 7.9% and of MDRTB was 1.5%. Multiple logistic regression analysis demonstrated that respiratory failure requiring mechanical ventilation (adjusted odds ratio [AOR] = 6.5; 95% confidence interval [CI] = 6.0 to 7.0; p < 0.001) and the presence of end-stage renal disease requiring dialysis (AOR = 7.0; 95% CI = 3.7 to 13.3; p = 0.002) were the largest contributors to mortality. Other variables independently associated with mortality included the presence of malnutrition (AOR = 3.2; 95% CI = 2.1 to 4.9; p = 0.007), age > 60 years (AOR = 3.5; 95% CI = 2.4 to 5.2; p < 0.001), drug-induced immunosuppression (AOR = 3.2; 95% CI = 1.6 to 5.2; p = 0.018), and dyspnea at the time of hospital presentation (AOR = 2.1; 95% CI = 1.4 to 3.1; p = 0.048). Overall, 45.3% of the patients had a > 7-day delay in the suspicion of the diagnosis of tuberculosis and the institution of antituberculosis therapy following hospital admission. There was no association between the presence of these delays and mortality.

CONCLUSIONS

Our data suggest that the 14-month mortality rate is high among patients diagnosed as having tuberculosis during hospitalization, despite low incidences of HIV infection and multidrug resistant disease. The factors that appear to contribute to this elevated mortality rate are markers of disease chronicity and severity of not only the tuberculosis, but also of the patient's underlying health status. Thus, while HIV positivity and multidrug resistance can be important determinants of mortality in some populations, other demographic factors and comorbid conditions may play a role as well. These data also suggest that tuberculosis is often superimposed on chronic illnesses that are important determinants of patient outcomes.

Ciprofloxacin once daily versus twice daily for the treatment of pulmonary tuberculosis

Ciprofloxacin was used as an antituberculous drug in adult patients who could not tolerate standard regimens or had to be treated with alternative combinations for resistance problems. During October 1986 to December 1991, 241 patients received ciprofloxacin in two daily 500 mg doses administered under supervision at 8.30 a.m. and 5 p.m., respectively. This group of patients was submitted to retrospective analysis for tolerability and clinical as well as microbiological efficacy. In January 1992, a once daily regimen with 1,000 mg of ciprofloxacin was introduced in order to simplify drug administration together with the other combination partners and to take advantage of higher drug levels at the site of infection. These patients were followed prospectively for safety and efficacy. Until July 1993, 227 patients with smear-positive pulmonary tuberculosis were included in this open study. Comparative analysis was carried out for a selected group of patients who had remained smear and culture positive for more than 27 days after start of treatment. Fifty-four patients who had received ciprofloxacin twice daily and 35 patients on the once daily regimen were evaluable. Both regimens were equally well tolerated. The once daily regimen was associated with a trend towards earlier conversion to smear negativity and a significantly shorter time to culture negativity. Smears became negative on average within 84 days with the once daily and in 94 days with the twice daily schedule (p = 0.19). Culture negativity occurred at 60 and 76 days in the respective groups (p = 0.0013; log Rank test). Of the patients who received ciprofloxacin twice daily, 33% were still smear and culture positive 90 days after start of treatment compared to only 15% of the patients treated with the once daily schedule. We conclude that ciprofloxacin, given as a single daily dose of 1,000 mg is as safe as two 500 mg doses, more convenient to apply and probably more efficacious.