Ambulatory-based standardized therapy for multi-drug resistant tuberculosis: experience from Nepal, 2005-2006

Abstract

Objective: The aim of this study was to describe treatment outcomes for multi-drug resistant tuberculosis (MDR-TB) outpatients on a standardized regimen in Nepal.

Methodology: Data on pulmonary MDR-TB patients enrolled for treatment in the Green Light Committee-approved National Programme between 15 September 2005 and 15 September 2006 were studied. Standardized regimen was used (8Z-Km-Ofx-Eto-Cs/16Z-Ofx-Eto-Cs) for a maximum of 32 months and follow-up was by smear and culture. Drug susceptibility testing (DST) results were not used to modify the treatment regimen. MDR-TB therapy was delivered in outpatient facilities for the whole course of treatment. Multivariable analysis was used to explain bacteriological cure as a function of sex, age, initial body weight, history of previous treatment and the region of report.

Principal findings: In the first 12-months, 175 laboratory-confirmed MDR-TB cases (62% males) had outcomes reported. Most cases had failed a Category 2 first-line regimen (87%) or a Category 1 regimen (6%), 2% were previously untreated contacts of MDR-TB cases and 5% were unspecified. Cure was reported among 70% of patients (range 38%-93% by Region), 8% died, 5% failed treatment, and 17% defaulted. Unfavorable outcomes were not correlated to the number of resistant drugs at baseline DST. Cases who died had a lower mean body weight than those surviving (40.3 kg vs 47.2 kg, p<0.05). Default was significantly higher in two regions [Eastern OR = 6.2; 95%CL2.0-18.9; Far West OR = 5.0; 95%CL1.0-24.3]. At logistic regression, cure was inversely associated with body weight <36 kg [Adj.OR = 0.1; 95%CL0.0-0.3; ref. 55-75 kg] and treatment in the Eastern region [Adj.OR = 0.1; 95%CL0.0-0.4; ref. Central region].

Conclusions: The implementation of an ambulatory-based treatment programme for MDR-TB based on a fully standardized regimen can yield high cure rates even in resource-limited settings. The determinants of unfavorable outcome should be investigated thoroughly to maximize likelihood of successful treatment.

Figure 1. MDR-TB treatment centers and sub-centers in Nepal.

Footnote Figure 1: In 2005–2006, not all the health centres were functioning. The 175 cases included in this study were under care at 17 clinics (Bhaktapur, Bheri, Bir, Genetup, Haraicha, HelpHand, INF_Banke, KohalpurMC, Mahakali, Mangalbare, NATA, NMC, NTC, Patan, RTC, Stupa, and TUTH).

Figure 2. Treatment outcomes for MDR-TB cases by region, Nepal, 2005–2006.

Figure 3. Months till death (N = 14, thick line) or default (N = 29, dotted line) for MDR-TB cases, Nepal, 2005–2006.