“The situation regarding MDR and XDR tuberculosis is bleak,” according to a commentary in response to a study looking at long-term outcomes of extensively drug-resistant tuberculosis patients in South Africa, published in The Lancet last week by Elize Pietersen and colleagues.
Researchers followed up with South African patients with XDR-TB who had been a part of an earlier study looking at early treatment outcomes in 2010. The study says that despite lengthy treatment with a median of eight anti-TB drugs, treatment outcomes were dismal: of 107 patients, only 17 were cured or completed treatment after 24 months, and 12 patients had similar favorable outcomes five years after treatment initiation. Forty nine patients died and 25 had failed treatment after 24 months of follow up. After 60 months, 79 patients had died and 11 had failed treatment. Of the 45 patients who were released into the community, 19 did not achieve sputum culture conversion.
Of the 79 patients who died, 32 were infected with HIV. “Twenty four (69%) of 53 patients living with HIV and receiving antiretroviral therapy had died by the end of follow-up, compared with 46 (73%) of 63 patients not infected with HIV and all nine patients with HIV not taking antiretroviral therapy,” the study says. A CD4 count of less than 200 was also associated with increased mortality, the study reports. The use of clofazamine in the treatment regimen seemed to reduce the risk of death.
“We have shown that long-term outcomes in patients with XDR tuberculosis are poor, irrespective of HIV status, although antiretroviral therapy has improved survival in patients with HIV,” the report states. “Many patients in our cohort who were discharged from hospital had positive sputum cultures, had failed treatment, and had no further therapeutic options. These patients survive for long periods living in the community and are likely to contribute to community-based spread of XDR tuberculosis.”
“Pietersen and colleague’s study should serve as another urgent alarm for global tuberculosis control: MDR disease in all its forms is an out-of-control problem with potentially vast and devastating repercussions for global public health,” the Lancet commentary says. “Clearly, drug regimens that are more effective and better tolerated are needed to improve adherence, decrease mortality, and prevent the amplification of tuberculosis drug resistance on treatment.”
Both the report and commentary call for policymakers and national control programs to urgently develop strategies to use existing public health instruments for TB control. They also argue for community-based interventions and the creation of palliative care facilities to minimize disease spread by patients who fail treatment.