Extensively drug-resistant tuberculosis: experience at the Tuberculosis Research Centre, Chennai, India

Ten extensively drug-resistant tuberculosis (XDR-TB) patients were identified among 104 human immunodeficiency virus negative multidrug-resistant tuberculosis (MDR-TB) patients treated at the Tuberculosis Research Centre, Chennai, India, in two different cohorts between 1999-2003 and 2006-2007. They were managed with individualised treatment regimens. At the time of diagnosis of MDR-TB, one patient had XDR-TB and three had initial ofloxacin resistance. One patient who had had a lobectomy in addition to chemotherapy became bacteriologically negative, three died, three defaulted and the remaining three, who are bacteriologically positive, are still continuing treatment. Although based on a small number of patients, our results have not been encouraging.

Perceptions of tuberculosis patients about private providers before and after implementation of Revised National Tuberculosis Control Programme

BACKGROUND

Most of the persons with chest symptoms in India approach private providers (PPs) for health care. It has been observed that patients who start treatment with PPs for tuberculosis (TB) frequently switch over subsequently to the public sector. The reasons for this discontinuation and their perceptions of the TB care provided by the PPs are unknown.

OBJECTIVE

To document the perceptions about PPs India's Revised National TB Control Programme (RNTCP) and the reasons for discontinuation of treatment with PPs and subsequent attendance at a public provider.

METHODS

This was a cross sectional study on patients registered under TB programme during 1997 and 2005 in rural and urban areas. During this period patients who were initially diagnosed and treated for TB in a private clinic and subsequently shifted to public health facility were considered for the study. A semi-structured interview schedule was used to collect the factors related to patient's perceptions on PPs, the factors responsible for initiating treatment with PPs, reasons for discontinuing treatment with PPs, and their willingness to continue treatment from government health facilities were collected. This data was compared with data collected in 1997 before implementation of the RNTCP.

RESULTS

A total of 1000 and 1311 TB patients were registered during 1997 and 2005 respectively. Among them, 203 (20%) and 104 (8%) patients were identified as having been initially diagnosed and started on TB treatment by PPs and subsequently shifted to government health facilities. There were significant changes in reasons for selecting PPs between the two periods: being convenient (47% vs 10%; p < 0.001), quality care (41% vs 19%; p < 0.001), motivated by others (49% vs 19%; p < 0.001), confidentiality (19% vs 9%; p < 0.05) and known doctor (6% vs 28%; p < 0.001) respectively. Financial problems were the most common reason for discontinuation of treatment in both periods. The use of sputum test for diagnosing TB by PPs was significantly increased after RNTCP implementation.

CONCLUSION

This study suggests that slowly perceptions of patients have changed towards PPs, and RNTCP has begun to gain acceptance amongst patients in terms of convenience, confidentiality and personal care.

Randomised controlled clinical trial of short course chemotherapy in abdominal tuberculosis: a five-year report

OBJECTIVES

To assess and compare the efficacy of a 6-month short-course chemotherapy regimen (SCC) with that of a 12-month standard regimen in the treatment of abdominal tuberculosis.

DESIGN AND SUBJECTS

A total of 193 adult patients with evidence of abdominal tuberculosis were randomly allocated to one of two daily regimens: 1) a 6-month SCC regimen with rifampicin, isoniazid and pyrazinamide for 2 months followed by rifampicin with isoniazid for another 4 months (6R series) and 2) and 12-month standard regimen of ethambutol and isoniazid with streptomycin supplemented for 2 weeks (12E series). Surgery was undertaken only for patients suspected to have obstruction or perforation of the intestine.

RESULTS

A total of 163 (85 6R, 78 12E) patients were available for efficacy analysis after exclusion of 30 patients for various reasons. At the end of treatment clinical status was normal in 84 (99%) in 6R patients and in 73 (94%) in 12E patients. Of these, 147 patients completed follow-up for 5 years; none had relapsed requiring treatment for abdominal tuberculosis.

CONCLUSION

A 6-month SCC regimen has been found to be as effective as the standard 12-month regimen in the treatment of all forms of abdominal tuberculosis.

Does Crohn's disease need differentiation from tuberculosis?

Crohn's disease (CD) and tuberculosis (TB) of the gastrointestinal tract pose major diagnostic problems for clinicians where these conditions coexist. Clinically and radiologically, the diseases are similar. In the West, TB is considered in the differential diagnosis of all suspected cases of CD, particularly among Asian migrants. Earlier age of presentation, perianal disease and enteric fistulae favour a diagnosis of CD. Aphthoid ulceration, pseudopolyps and filiform mucosa at endoscopy are suggestive of CD and a negative tuberculin test us useful. The final diagnosis depends largely on histopathology and the presence or absence of acid fast bacilli. Tuberculosis is more common in developing countries and intestinal TB frequently coexists with pulmonary tuberculosis. TB is known to affect all age groups and fistulous communication, although uncommon, does occur. In addition to radiology and endoscopy, laparotomy may be required to establish the diagnosis. In developing countries, CD is uncommon and remains largely a diagnosis of exclusion. A trial of anti-tuberculosis therapy may often be prescribed before definitely diagnosing CD. The development of molecular biology techniques had led to a revival of interest in mycobacteria as a possible aetiological agent in CD. DNA from Mycobacterium paratuberculosis and Mycobacterium kansaii have both been identified in CD cases but the significance of this finding has not been established. However, in the near future polymerase chain reaction will become increasingly useful in differentiating CD from intestinal TB because it allows the amplification and identification of very small quantities of mycobacterium DNA.

A direct rifampicin sensitivity test for tubercle bacilli

A direct sensitivity test for rifampicin has been standardised for early detection of resistance for the mycobacterium tuberculosis smear positive sputum samples. Indirect sensitivity tests set up from primary cultures of the same samples served as controls. The direct test showed 95 per cent agreement with the standard indirect test and as such 74 per cent and 90 per cent of the resistant strains were detected by the fourth week and fifth week, respectively, with an overall gain of 4-5 wks time. Resistance could be detected earlier for multibacillary specimens. This direct sensitivity test on Lowenstein Jensen (LJ) medium offers a feasible alternative for laboratories which lack facilities to perform drug susceptibility tests by the rapid but sophisticated and costly BACTEC method. The method is simple to perform, economic, reliable and amenable to confirmation by the indirect test, if needed.

A controlled clinical trial of short-course chemotherapy for tuberculoma of the brain

OBJECTIVE

The efficacy of a short-course regimen in the treatment of brain tuberculoma and computerised tomography (CT) scan appearance before, during and after antituberculosis treatment was studied in a controlled clinical trial.

DESIGN

Patients aged over 5 years with tuberculoma of the brain diagnosed by CT scan were randomly allocated to one of the following 2 regimens: Regimen 1: rifampicin, isoniazid and pyrazinamide daily for an initial 3 months followed by rifampicin and isoniazid twice-weekly for 6 months. Regimen 2: rifampicin, isoniazid and pyrazinamide thrice-weekly for an initial 3 months followed by rifampicin and isoniazid twice-weekly for 6 months. The patients were followed intensively for 2 years from the start of treatment.

RESULTS

Of the 108 patients analysed (regimen 1: 56, regimen 2: 52), at the end of treatment clinical status was normal in 91% in regimen 1 and 88% in regimen 2. Of the 91 patients with scan assessments, CT scan lesions disappeared at 24 months in 77% of 47 patients in regimen 1 and 80% of 44 in regimen 2, and in both groups 88% of the patients were clinically normal. None had relapses requiring treatment.

CONCLUSIONS

Short-course regimens of 9 months' duration are effective in the treatment of tuberculoma of the brain; clinical recovery was faster than scan clearance.