Outcome of standardized treatment for patients with MDR-TB from Tamil Nadu, India

BACKGROUND & OBJECTIVES

Programmatic management of MDR-TB using a standardized treatment regimen (STR) is being implemented under the Revised National Tuberculosis Control Programme (RNTCP) in India. This study was undertaken to analyse the outcomes of MDR-TB patients treated at the Tuberculosis Research Centre, Chennai, with the RNTCP recommended 24 months STR, under programmatic conditions.

METHODS

Patients failed to the category II re-treatment regimen and confirmed to have MDR-TB, were treated with the RNTCP's STR in a prospective field trial on a predominantly ambulatory basis. Thirty eight patients were enrolled to the trial from June 2006 to September 2007.

RESULTS

Time to culture conversion was two months or less for 82 per cent of patients. Culture conversion rates at 3 and 6 months were 84 and 87 per cent respectively. At the end of treatment, 25 (66%) were cured, 5 defaulted, 3 died and 5 failed. At 24 months, 30 (79%) patients, including 5 defaulters, remained culture negative for more than 18 months. Twenty two (58%) patients reported adverse drug reactions (ADRs) which required dose reduction or termination of the offending drug. No patient had XDR-TB initially, but 2 failure cases emerged as XDR-TB during treatment.

INTERPRETATION & CONCLUSIONS

Outcomes of this small group of MDR-TB patients treated with the RNTCP's STR is encouraging in this setting. Close attention needs to be paid to ensure adherence, and to the timely recognition and treatment of ADRs.

Management of multi drug resistance tuberculosis in the field: Tuberculosis Research Centre experience

SETTING

Multi-drug TB resistant (resistant to isoniazid and rifampicin) patients identified from a rural and urban area.

OBJECTIVE

To study the feasibility of managing MDR TB patients under field conditions where DOTS programme has been implemented.

METHODS

MDR TB Patients identified among patients treated under DOTS in the rural area and from cases referred by the NGO when MDR TB was suspected form the study population. Culture and drug susceptibility testing were done at Tuberculosis Research Centre (TRC). Treatment regimen was decided on individual basis. After a period of initial hospitalization, treatment was continued in the respective peripheral health facility or with the NGO after identifying a DOT provider in the field. Patients attended TRC at monthly intervals for clinical, sociological and bacteriological evaluations. Drugs for the month were pre-packed and handed over to the respective center.

RESULTS

A total of 66 MDR TB patients (46 from the rural and 20 from the NGO) started on treatment form the study population and among them 20 (30%) were resistant to one or more second line drugs (Eto, Ofx, Km) including a case of "XDR TB". Less than half the patients stayed in the hospital for more than 10 days. The treatment was provided partially under supervision. Providing injection was identified to be a major problem. Response to treatment could be correctly predicted based on the 6-month smear results in 40 of 42 regular patients. Successful treatment outcome was observed only in 37% of cases with a high default of 24%. Adverse reactions necessitating modification of treatment was required only for three patients.

IMPLICATIONS

Despite having reliable DST and drug logistics, the main challenge was to maintain patients on such prolonged treatment by identifying a provider closer to the patient who can also give injection, have social skills and manage of minor adverse reactions.

Simultaneous infection with multiple strains of Mycobacterium tuberculosis identified by restriction fragment length polymorphism analysis

Simultaneous infection with multiple strains of Mycobacterium tuberculosis was confirmed in two isolates of a total of 543 culture-positive tuberculosis patients from the Model DOTS area of Thiruvallur, South India, using IS6110 and direct repeat restriction fragment length polymorphism (DR-RFLP). The two isolates showing different intensities of IS6110 band patterns were further analysed by repeating RFLP on their alternate cultures and individual colonies. The results showed respectively two and three distinct IS6110 RFLP patterns, indicating mixed infection. The possibility of cross contamination at laboratory or DNA level was ruled out. Additional DR-RFLP also confirmed infection with multiple strains. This study found evidence of co-infection with two or three different strains of M. tuberculosis, showing distinct RFLP patterns.

Evaluation of the phenol ammonium sulfate sedimentation smear microscopy method for diagnosis of pulmonary tuberculosis

We compared the sensitivity and specificity of the phenol ammonium sulfate (PhAS) sediment smear microscopy method for detection of acid-fast bacilli with those of direct smear microscopy, using culture results for Mycobacterium tuberculosis as the "gold standard." The sensitivities of the PhAS and direct smear methods were 85% (465 of 547) and 83% (454 of 547), respectively, and the specificity of each method was 97%. The PhAS method was better accepted by the laboratory technicians and safer but necessitates an overnight sedimentation, which delays reporting of results until 1 day after sputum collection.