Patient and health care system delays in the diagnosis and treatment of tuberculosis.

SETTING: All culture-positive tuberculosis patients without previous treatment for tuberculosis (n = 184), New York City, April 1994. OBJECTIVE: To examine factors associated with delays in presenting to a health care provider (patient delay) and in starting antituberculosis treatment (health care system delay). DESIGN: Retrospective medical record review and patient interviews. RESULTS: Median total delay was 57 days (range 4-764), 35 for acid-fast bacilli smear-positive patients and 79 for smear-negative patients (P < 0.001). Median patient delay was 25 (range 0-731). Median health care system delay was 15 days, 6 for smear-positive patients and 31 for smear-negative patients (P < 0.001). In logistic regression, age 55-64 years (adjusted odds ratio [OR(adj)] 10.6, 95% confidence interval [CI] 1.3-86.9), and primary language other than English (OR(adj) 2.5, 95%CI 1.0-5.8), were associated with longer patient delays. Homelessness (OR(adj) 7.1, 95%CI 1.05-33.5), not having a chest radiograph at the first medical visit (OR(adj) 2.4, 95%CI 1.0-5.4), negative smear (OR(adj) 10.2, 95%CI 4.4-23.3) and absence of cough (OR(adj) 2.9, 95%CI 1.2-6.8) were associated with longer health care system delays. CONCLUSION: To reduce delays, patients should be educated to seek care more quickly, and should be provided with culturally appropriate health care and language services. Physicians should maintain a high index of suspicion for tuberculosis and perform appropriate diagnostic tests.

A multi-institutional outbreak of highly drug-resistant tuberculosis: epidemiology and clinical outcomes.

OBJECTIVE: To investigate a multi-institutional outbreak of highly resistant tuberculosis and evaluate patient outcome. DESIGN: Epidemiologic investigation of every tuberculosis case reported in New York City. SETTING: Patients cared for at all public and nonpublic institutions from January 1, 1990, to August 1, 1993 (43 months). PATIENTS: We reviewed medical and public health records and conducted clinical, epidemiologic, drug susceptibility, and restriction fragment length polymorphism (RFLP) analyses. A case was defined as tuberculosis in a patient with an isolate resistant to isoniazid, rifampin, ethambutol hydrochloride, and streptomycin (and rifabutin, if sensitivity testing included it), and, if RFLP testing was done, a pattern identical to or closely related to strain W. MAIN OUTCOME MEASURES: Patient survival and the conversion of sputum cultures from positive to negative. RESULTS: Of the 357 patients who met the case definition, 267 had identical or nearly identical RFLP patterns; isolates from the other 90 patients were not available for RFLP testing. Among these 267 patients, 86% were human immunodeficiency virus (HIV)-infected, 7% were HIV-negative, and 7% had unknown HIV status. All-cause mortality was 83%. Epidemiologic linkages were identified for 70% of patients, of whom 96% likely had nosocomially acquired disease at 11 hospitals. Survival was prolonged among patients who received medications to which their isolate was susceptible, especially capreomycin sulfate, and among patients with a CD4+ T-lymphocyte count greater than 0.200 x 10(9)/L (200/microL). Treatment with isoniazid and a fluoroquinolone antibiotic was also independently associated with longer survival. CONCLUSIONS: This outbreak accounted for nearly one fourth of the cases of multidrug-resistant tuberculosis in the United States during a 43-month period. Most patients had nosocomially acquired disease, were infected with HIV, and unless promptly and appropriately treated, died rapidly. With appropriate directly observed treatment, especially combinations including an injectable medication, even severely immunocompromised patients had culture conversion and prolonged, tuberculosis-free survival.