Community-Based Therapy for Multidrug-Resistant Tuberculosis in Lima, Peru

TLDR

Multidrug‑resistant tuberculosis is common in low‑income countries, but treatment is considered too costly and infeasible outside referral centers, and early initiation of appropriate therapy can preserve first‑line drug susceptibility and improve outcomes. The study evaluated community‑based, ambulatory treatment of MDR tuberculosis in a poor district of Lima, Peru, describing the first 75 patients receiving individualized regimens. The authors retrospectively reviewed charts of all program participants from August 1996 to February 1999, noting that the infecting strains were resistant to a median of six drugs, and identified predictors of poor outcomes. Among 66 patients completing ≥4 months, 83 % were probably cured, only one remained culture‑positive after six months, five died, and failures or deaths were linked to extensive bilateral disease, low hematocrit, and low BMI, while inclusion of pyrazinamide and ethambutol was associated with better outcomes, demonstrating that community‑based outpatient therapy can achieve high cure rates in resource‑poor settings.

Abstract

Despite the prevalence of multidrug-resistant tuberculosis in nearly all low-income countries surveyed, effective therapy has been deemed too expensive and considered not to be feasible outside referral centers. We evaluated the results of community-based therapy for multidrug-resistant tuberculosis in a poor section of Lima, Peru.We describe the first 75 patients to receive ambulatory treatment with individualized regimens for chronic multidrug-resistant tuberculosis in northern Lima. We conducted a retrospective review of the charts of all patients enrolled in the program between August 1, 1996, and February 1, 1999, and identified predictors of poor outcomes.The infecting strains of Mycobacterium tuberculosis were resistant to a median of six drugs. Among the 66 patients who completed four or more months of therapy, 83 percent (55) were probably cured at the completion of treatment. Five of these 66 patients (8 percent) died while receiving therapy. Only one patient continued to have positive cultures after six months of treatment. All patients in whom treatment failed or who died had extensive bilateral pulmonary disease. In a multiple Cox proportional-hazards regression model, the predictors of the time to treatment failure or death were a low hematocrit (hazard ratio, 4.09; 95 percent confidence interval, 1.35 to 12.36) and a low body-mass index (hazard ratio, 3.23; 95 percent confidence interval, 0.90 to 11.53). Inclusion of pyrazinamide and ethambutol in the regimen (when susceptibility was confirmed) was associated with a favorable outcome (hazard ratio for treatment failure or death, 0.30; 95 percent confidence interval, 0.11 to 0.83).Community-based outpatient treatment of multidrug-resistant tuberculosis can yield high cure rates even in resource-poor settings. Early initiation of appropriate therapy can preserve susceptibility to first-line drugs and improve treatment outcomes.