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Mortality among tuberculosis patients with acquired resistance to second-line anti-tuberculosis drugs — United States, 1993–2008

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  • Alternative Title:
    Clin Infect Dis
  • Description:
    Background Resistance to second-line anti-tuberculosis drugs (SLD) severely compromises treatment options of drug-resistant tuberculosis (TB). We assessed the association between acquisition of resistance (AR) to second-line injectable drugs (SLI) or fluoroquinolones (FQ) and mortality among TB cases confirmed by positive culture results with available initial and final drug susceptibility test (DST) results. Methods We analyzed data from U.S. National TB Surveillance System, 1993–2008. Acquired resistance was defined as drug susceptibility at initial DST but resistance to the same drug at final DST. We compared survival with Kaplan-Meier curves and analyzed the association between AR and mortality using a univariate extended Cox proportional hazards model adjusted for age. Results Of 2,329 cases with both initial and final DST to SLI, 49 (2.1%) acquired resistance; 13/49 (26.5%) had treatment terminated by death versus 222 (10.0%) of those without AR to SLI (P<0.001). Of 1,187 cases with both initial and final DST to FQ, 32 (2.8%) acquired resistance; 12/32 (37.5%) had treatment terminated by death versus 121 (10.9%) of those without AR to FQ (P=0.001). Controlling for age, mortality was significantly greater among cases with AR to SLD than among cases without AR (adjusted hazard ratio (aHR)[SLI], 2.8; 95% confidence interval (CI),1.4–5.4; aHR[FQ], 1.9; 95% CI,1.0–3.5). MDR TB at treatment initiation, positive HIV status, and extrapulmonary disease were also significantly associated with mortality. Conclusion Mortality was significantly greater among TB cases with AR to SLD. Providers should consider AR to SLD early in treatment, monitor DST results, and avoid premature deaths.
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