Use of drug-susceptibility testing for management of drug-resistant tuberculosis, Thailand, 2004-2008.

In 2004, routine use of culture and drug-susceptibility testing (DST) was implemented for persons in 5 Thailand provinces with a diagnosis of tuberculosis (TB). To determine if DST results were being used to guide treatment, we conducted a retrospective chart review for patients with rifampin-resistant or multidrug-resistant (MDR) TB during 2004-2008. A total of 208 patients were identified. Median time from clinical sample collection to physician review of DST results was 114 days. Only 5.8% of patients with MDR TB were empirically prescribed an appropriate regimen; an additional 31.3% received an appropriate regimen after DST results were reviewed. Most patients with rifampin -resistant or MDR TB had successful treatment outcomes. Patients with HIV co-infection and patients who were unmarried or had received category II treatment before DST results were reviewed had less successful outcomes. Overall, review of available DST results was delayed, and results were rarely used to improve treatment.

Factors associated with death among HIV-uninfected TB patients in Thailand, 2004-2006.

OBJECTIVES: In countries with both TB and human immunodeficiency virus (HIV) epidemics, HIV is known to be the most powerful risk factor for death during tuberculosis (TB) treatment. Few recent studies have evaluated risk factors for death among HIV-uninfected TB patients in these countries. We analysed data from a multi-province demonstration project in Thailand to answer this question. METHOD: We prospectively collected data from HIV-uninfected TB patients treated for TB in four provinces and the national infectious diseases hospital in Thailand from 2004-2006. Standard WHO definitions were used to classify treatment outcomes. We used log-binomial multivariate regression to calculate adjusted relative risk (aRR) and 95% confidence intervals (CI) for factors associated with death. RESULTS: Of 5318 cases, 441 (8%) died during TB treatment. The mean age was 47 years (range 8 months-97 years). Multidrug-resistant (MDR)-TB was diagnosed in 62 (1%). In multivariate analysis, patients older than 44 years were significantly more likely to die than patients aged 15-44 years [age 45-64, aRR 2.9 (CI 2.2-3.8)] [age > 64 years, aRR 5.0 (CI 3.9-6.6)]. Other independent risk factors for death included Thai nationality [aRR 3.9 (CI 1.6-9.5)], MDR-TB [aRR 2.8 (CI 1.7-4.8)], not being married [aRR 1.4 (CI 1.2-1.7)], and living in Chiang Rai province [aRR 2.7 (CI 1.7-4.4)]. CONCLUSIONS: The death rate was high among HIV-uninfected TB patients in Thailand. Efforts to improve TB diagnosis and treatment in the elderly and to improve MDR-TB treatment may help reduce mortality.

Directly observed therapy and improved tuberculosis treatment outcomes in Thailand.

BACKGROUND: The World Health Organization (WHO) recommends that tuberculosis (TB) patients receive directly observed therapy (DOT). Randomized controlled trials have not consistently shown that this practice improves TB treatment success rates. In Thailand, one of 22 WHO-designated high burden TB countries, patients may have TB treatment observed by a health care worker (HCW), family member, or no one. We studied whether DOT improved TB treatment outcomes in a prospective, observational cohort. METHODS AND FINDINGS: We prospectively collected epidemiologic data about TB patients treated at public and private facilities in four provinces in Thailand and the national infectious diseases hospital from 2004-2006. Public health staff recorded the type of observed therapy that patients received during the first two months of TB treatment. We limited our analysis to pulmonary TB patients never previously treated for TB and not known to have multidrug-resistant TB. We analyzed the proportion of patients still on treatment at the end of two months and with treatment success at the end of treatment according to DOT type. We used propensity score analysis to control for factors associated with DOT and treatment outcome. Of 8,031 patients eligible for analysis, 24% received HCW DOT, 59% family DOT, and 18% self-administered therapy (SAT). Smear-positive TB was diagnosed in 63%, and 21% were HIV-infected. Of patients either on treatment or that defaulted at two months, 1601/1636 (98%) patients that received HCW DOT remained on treatment at two months compared with 1096/1268 (86%) patients that received SAT (adjusted OR [aOR] 3.8; 95% confidence interval [CI] 2.4-6.0) and 3782/3987 (95%) patients that received family DOT (aOR 2.1; CI, 1.4-3.1). Of patients that had treatment success or that defaulted at the end of treatment, 1369/1477 (93%) patients that received HCW DOT completed treatment compared with 744/1074 (69%) patients that received SAT (aOR 3.3; CI, 2.4-4.5) and 3130/3529 (89%) patients that received family DOT (aOR 1.5; 1.2-1.9). The benefit of HCW DOT compared with SAT was similar, but smaller, when comparing patients with treatment success to those with death, default, or failure. CONCLUSIONS: In Thailand, two months of DOT was associated with lower odds of default during treatment. The magnitude of benefit was greater for DOT provided by a HCW compared with a family member. Thailand should consider increasing its use of HCW DOT during TB treatment.