Evaluation of a directly observed six months fully intermittent treatment regimen for tuberculosis in patients suspected of poor compliance

Diagnosis and Treatment of Skipped Multifocal Spinal Tuberculosis Lesions

Spinal tuberculosis, also known as Pott's disease or tuberculous spondylitis, is usually secondary to primary infection in the lungs or other systems, and in most instances, is thought to be transmitted via blood. Typical manifestations of infection include narrowing of the intervertebral disc by erosion and bone destruction of adjacent vertebrae. Atypical spinal tuberculosis is a specific type of spinal tuberculosis. It mainly consists of single vertebral lesions, single posterior structure lesions, multiple vertebral lesions, and intra-spinal lesions. Skipped multifocal spinal tuberculosis is one of these types and is characterized by two or more vertebral lesions without the involvement of the adjoining intervertebral discs, regardless of their location. To date, only a few cases have been reported. Upon clinical admission, it can be treated conservatively or surgically, depending on the patient's symptoms. In addition, gene or biological therapies are being investigated. However, because of the exceptional imaging findings and insidious symptoms, it is often misdiagnosed as a neoplastic lesion, osteoporotic fracture, or other infectious spondylitis, increasing the risk of neurological deficit and kyphotic deformity, and delaying the optimal treatment window. In this study, we review the diagnosis and treatment strategies for skipped multifocal spinal tuberculosis lesions and enumerate the common differential diagnoses, to provide reference and guidance for clinical treatment and diagnosis direction.

Compliance with tuberculosis treatment after the implementation of the directly observed treatment, short-course strategy in the city of Carapicuíba, Brazil

OBJECTIVE

To determine the compliance with tuberculosis treatment among patients enrolled the tuberculosis control program in the city of Carapicuíba, Brazil, before and after the implementation of the directly observed treatment, short-course (DOTS) strategy.

METHODS

A retrospective historical cohort study of operational aspects based on records of attendance and treatment evolution of patients in self-administered treatment (SAT) and of those submitted to DOTS. Monthly treatment outcome tables were created, and the probability of compliance with the treatment was calculated for both groups of patients.

RESULTS

A total of 360 patients with tuberculosis met the inclusion criteria: 173 (48.1%) in the SAT group; and 187 (51.9%) in the DOTS group. Treatment compliance was 6.1% higher in the DOTS group than in the SAT group. The proportion of patients completing the six months of treatment was 91.6% and 85.5% in the DOTS group and in the SAT group, respectively.

CONCLUSIONS

The results of this study show that DOTS can be successfully implemented at primary health care clinics. In this population of patients, residents of a city with low incomes and a high burden of tuberculosis infection, DOTS was more effective than was SAT.

Prevalência de Mycobacterium tuberculosis resistente em pacientes sob tratamento parcialmente intermitente ou sob tratamento diário

OBJETIVO: Comparar as taxas de prevalência de Mycobacterium tuberculosis resistentes entre pacientes sob tratamento parcialmente intermitente e daqueles sob tratamento diário. MÉTODOS: Foram utilizados dados da Organização Mundial de Saúde de 5.138 pacientes com TB pulmonar bacilífera no Brasil, que foram separados em dois grupos: um grupo de pacientes do Distrito Federal submetidos a um regime intermitente de três tomadas semanais após o primeiro mês de regime diário, e um grupo de pacientes dos estados brasileiras, submetidos somente a um regime diário. O padrão de resistência foi categorizado em resistência primária ou adquirida, conforme a existência de tratamento anterior. Além disso, multirresistência foi definida como a resistência simultânea à isoniazida e à rifampicina, enquanto monorresistência como a resistência a uma única droga. RESULTADOS: A prevalência da resistência primária como um todo no Distrito Federal e no restante do Brasil foi de 9,2% e 9,3% (p = 0,94), respectivamente. A prevalência de monorresistência foi de 6,6% e 6,9% (p = 0,89), respectivamente, e a de multirresistência, 1,0% e 1,2% (p = 0,85), respectivamente. A prevalência de resistência adquirida como um todo no Distrito Federal e no restante do Brasil foi de 15,8% e 26,8% (p = 0,39), respectivamente. A prevalência de monorresistência adquirida foi de 5,3% e 13,7% (p = 0,33), respectivamente, e a de multirresistência, 0,0% e 10,2% (p = 0,16), respectivamente. CONCLUSÕES: Não houve diferença significativa entre os índices de resistência observados na comunidade usuária do esquema parcialmente intermitente e do diário.

Tuberculosis and illicit drug use: review and update

Illicit drug users continue to be a group at high risk for tuberculosis (TB). Here, we present an updated review of the relationship between TB and illicit drug use, and we summarize more than a decade of new research. Drug users, and injection drug users in particular, have driven TB epidemics in a number of countries. The successful identification and treatment of TB among illicit drug users remain important components of a comprehensive TB strategy, but illicit drug users present a unique set of challenges for TB diagnosis and control. New diagnostic modalities, including interferon-gamma-release assays, offer potential for improved diagnosis and surveillance among this group, along with proven treatment strategies that incorporate the use of directly observed therapy with treatment for drug abuse. Special considerations, including coinfection with viral hepatitis and the rifampin-methadone drug interaction, warrant clinical attention and are also updated here.

A follow up study on revised national tuberculosis control programme (rntcp): results from a single centre study

OBJECTIVE

To know the follow up status of tuberculosis patients after 1 year of completion of treatment in RNTCP. MATERIALS #ENTITYSTARTX00026;

METHODS

Those patients of tuberculosis, who were registered from June 2003 to June 2004 at DOTS centre of our institution, were followed up at their homes after one year of completion of treatment between August 2005 and August 2006, with the help of health visitor. Patients were followed up clinically and symptomatic patients were also followed radiologically as well as bacteriologicalty. Results of the study were recorded in terms of number of patients remained asymptomatic, number of patients relapsed and number of patients died.

RESULTS

Out of 237 patients registered, 8 patients died during treatment period, 12 patients defaulted the treatment, the number of failures was 5 and 212 patients were declared cured/treatment completed. Out of these 212 patients 60 were unavailable for interview due to various reasons. The study observed that out of a total of 152 patients interviewed, 137 patients (90.1%) of remained asymptomatic, 11 patients (7.2%) had relapsed and 4 patients (2.6%) died during follow up.

CONCLUSION

The study observed that majority of patients (90.1%) re-mained asymptomatic after the completion of one year of treatment under DOTS.

Exploring the efficacy of a case management model using DOTS in the adherence of patients with pulmonary tuberculosis

AIM

To explore the efficacy of hospitals using case management with Directly Observed Treatment - Short course (DOTS) to monitor the adherence of patients with pulmonary tuberculosis in Taiwan.

BACKGROUND

Non-adherence to anti-tuberculosis chemotherapy is the major problem in treating patients with tuberculosis. Community-based case management coupled with DOTS has been applied to patients with tuberculosis and has resulted in good results in some countries. Taiwan has a high incidence of tuberculosis, and although it has implemented DOTS, the expected increased efficacy has not yet been realized.

DESIGN AND METHODS

The study used a quasi-experimental design. Using age and gender as matching factors, 96 subjects were randomly assigned to one of three groups in 2002-2003. Experimental group I was to receive DOTS case management comprising in-hospital education, direct daily observation in the first two months and one home visit per week. Experimental group II received traditional case management comprising in-hospital education and one home visit per month. The control group did not receive any intervention.

RESULTS

The adherence, the rate of completion, the treatment success, sputum conversion and chest X-ray improvement of experimental group I were significantly improved compared with experimental group II and the control group. The completion rate in experimental group I was higher than the general rate for Taiwan during the past six years and the treatment success rate met the standards of the World Health Organization.

CONCLUSION

Hospitals using case management with DOTS can improve the adherence of tuberculosis patients and the control of tuberculosis-epidemic situations. Relevance to clinical practice. In a rapidly changing healthcare environment, clinical nurses can make a significant contribution to healthcare delivery for tuberculosis patients. This study has provided further insight into the implementation of hospital-to-community level case management using DOTS by nurses.

International standards for tuberculosis care

Part of the reason for failing to bring about a more rapid reduction in tuberculosis incidence worldwide is the lack of effective involvement of all practitioners-public and private-in the provision of high quality tuberculosis care. While health-care providers who are part of national tuberculosis programmes have been trained and are expected to have adopted proper diagnosis, treatment, and public-health practices, the same is not likely to be true for non-programme providers. Studies of the performance of the private sector conducted in several different parts of the world suggest that poor quality care is common. The basic principles of care for people with, or suspected of having, tuberculosis are the same worldwide: a diagnosis should be established promptly; standardised treatment regimens should be used with appropriate treatment support and supervision; response to treatment should be monitored; and essential public-health responsibilities must be carried out. Prompt and accurate diagnosis, and effective treatment are essential for good patient care and tuberculosis control. All providers who undertake evaluation and treatment of patients with tuberculosis must recognise that not only are they delivering care to an individual, but they are also assuming an important public-health function. The International Standards for Tuberculosis Care (ISTC) describe a widely endorsed level of care that all practitioners should seek to achieve in managing individuals who have, or are suspected of having, tuberculosis. The document is intended to engage all care providers in delivering high quality care for patients of all ages, including those with smear-positive, smear-negative, and extra-pulmonary tuberculosis, tuberculosis caused by drug-resistant Mycobacterium tuberculosis complex, and tuberculosis combined with HIV infection.

[Controversies in the treatment of extrapulmonary tuberculosis]

Tuberculosis (TB) can spread to any tissue or organ of the body by way of hematogenous or lymphatic dissemination or contiguity. However, pulmonary TB is the most common presentation and the only form of the disease of epidemiologic importance. Consequently, the literature on the various forms of extrapulmonary TB (EPTB) is scant, and most of the published authors are specialists in specific extrapulmonary forms. As a result, in most of the major areas of study of EPTB, recommendations similar to those for pulmonary TB or others based on little or no evidence have been accepted. This lack of evidence is of particular concern in the case of treatment guidelines. The present article reviews important work that has given rise to current treatment guidelines. While most of these guidelines reveal the lack of evidence available on this subject, it can, nevertheless, be concluded that a 6-month treatment regimen similar to that used in patients with pulmonary TB may be sufficient to treat all forms of EPTB, including meningeal disease. The role of steroids and surgery in the treatment of TB affecting different sites is also discussed. Other topics dealt with are the considerations that should be taken into account and the treatment modifications necessary in patients infected with the human immunodeficiency virus.

Factors associated with tuberculosis treatment interruption in New York City

SETTING

Large urban tuberculosis control program.

OBJECTIVES

To determine the frequency and characteristics of treatment interruptions, and the factors associated with the different types of treatment interruptions.

DESIGN

This was a case-control study using culture-positive tuberculosis (TB) patients verified in 1998-1999. Case patients included those in whom any of the following mutually exclusive categories of treatment interruption: default with return to therapy, directly observed therapy nonadherence, default without return to therapy, or multiple types of interruptions. Controls were selected randomly from the cohort.

RESULTS

Overall, 6.0 percent of patients had treatment interruptions. All types of treatment interruption were associated with prolonged treatment course and decreased treatment completion rates. The median number of months to treatment interruption was 4.0 (range, 0.5-28.9 months). Two factors were significantly associated with every type of interruption: homelessness and lack of awareness of the severity of TB disease. In multivariate analysis, only lack of awareness of the severity of disease remained independently associated with all interruption types.

CONCLUSION

Efforts to improve patients' understanding of TB disease and related treatment issues may be an important TB control program strategy and should be emphasized at the initiation of therapy and at intervals throughout the treatment course to minimize treatment interruption.

[Social risk factors for noncompliance with tuberculosis treatment in Pontevedra [Spain]]

OBJECTIVE

To determine the prevalence and characteristics of social risk factors (SRF) for noncompliance with treatment in patients with tuberculosis (TB) in Pontevedra.

METHODS

We performed a descriptive analysis of patients with TB and SRF diagnosed between 1996 and 2002. A patient was considered as having SRF if he or she was socially isolated (alcoholism, intravenous drug use, prison inmate, homelessness or social maladjustment) or was an immigrant. The prevalence, annual trend of SRF and patient outcomes were calculated. The influence of direct observation of treatment administration on the outcome of patients with SRF was also analyzed.

RESULTS

Of 775 patients with TB, 156 (20.1%) had at least one SRF. Eighty-six patients were alcoholic, 41 were intravenous drug users, 24 were immigrants, 11 were homeless, 11 showed social maladjustment and 10 were prison inmates. The presence of SRF among TB patients showed no tendency to increase or decrease during the study period, except for the increasing number of immigrants (chi 2 for lineal tendency = 12.24; p = 0.005). Final outcomes were significantly better in patients without SRF (90.4 vs 70.8% of satisfactory final outcomes; p < 0.001). Direct observation of treatment did not increase satisfactory outcomes in patients with SRF.

CONCLUSIONS

Patients with TB and SRF have a significantly higher proportion of unsatisfactory final outcomes. The presence of SRF is relatively low in our environment. The number of immigrants from countries with a high prevalence of TB shows an incipient tendency to increase. This finding should be taken into account to achieve better control of the disease.

Epidemiology of tuberculosis on Gran Canaria: a 4 year population study using traditional and molecular approaches

BACKGROUND

In recent years several population based studies using restriction fragment length polymorphism (RFLP) analysis have shown a higher rate of recent transmission of tuberculosis than previously thought. This study was undertaken to determine the transmission patterns of tuberculosis and the potential causes of recent transmission on the island of Gran Canaria (Spain).

METHODS

The strains of all patients diagnosed with tuberculosis confirmed by culture between 1 January 1993 and 31 December 1996 were typed by RFLP using the insertion sequence IS6110. A cluster was defined as two or more isolates with an identical RFLP pattern. Epidemiological linkage through contact tracing was investigated.

RESULTS

Of the total of 719 patients, 153 (21.3%) were excluded because there was inadequate bacterial DNA for genotyping (n=129) or the isolates of Mycobacterium tuberculosis had less than five copies of IS6110 (n=24). The isolates from 409 patients (72.3%) were grouped into 78 different clusters with an estimated 58.5% of the cases being due to recent transmission. Young age was the only significant predictor of clustering. Only in 147 (35.9%) of the 409 patients belonging to a cluster could an epidemiological link be found. 111 patients (19.6%) were identified as having had previous contact with a tuberculosis patient and 81 of them (72.9%) belonged to a cluster. The three largest clusters included 75, 49 and 20 patients, respectively.

CONCLUSION

Recent transmission is frequent among patients with tuberculosis on Gran Canaria and could be associated with certain aspects of control measures. Some of the clusters described in the study could be due to the prevalence of particular strains of M tuberculosis on the island.

Homelessness and substance misuse: a tale of two cities

In this article we examine the relationship between alcohol and drug misuse among the literally homeless (those living out of doors and in emergency shelters) in Hartford, Connecticut and Providence, Rhode Island, two northeastern U.S. cities of comparable size. We worked with homeless advocacy organizations in both cities, using a point-in-time census (N = 1058) and random sample (N = 66) in Hartford, and a sampling of clients (N = 82) of six shelters serving residents of Providence (N = 82). We found substance misuse relevant in 47.2% of the homeless in Hartford and in 45.1% of the homeless in Providence. We conclude that there is a great need for substance treatment services inside shelters, soup kitchens, and day centers so that homeless individuals have an opportunity to engage in treatment within their own milieu.

A controlled trial of methadone treatment combined with directly observed isoniazid for tuberculosis prevention in injection drug users

Substance abuse is associated with high risk for tuberculosis (TB) and poor adherence to medication regimens. This study compared completion rates for isoniazid (INH) preventive therapy for injection drug users (IDUs) randomly assigned to methadone treatment combined with directly observed preventive treatment (DOPT) versus those assigned to routine TB clinic referral without methadone treatment. One hundred and eleven opioid-dependent patients with latent TB were assigned to one of three 6-month treatment conditions: standard methadone treatment including substance abuse counseling combined with daily INH DOPT (n=37); minimal methadone treatment without counseling, also combined with daily INH DOPT (n=35); or routine care referral to TB clinic for monthly INH supplies without DOPT and without methadone treatment (n=39). INH completion rates were 77.1% for minimal methadone and 59.5% for standard methadone, as compared with only 13.5% for routine care (P<0.0001). Mean duration of INH treatment retention was 5.7, 5.0 and 1.6 months, respectively (P<0.0001). TB incidence at 4-year follow-up was 0 of 54 subjects who completed preventive therapy versus 2 of 57 who failed to complete. One of these two had been assigned to routine care, and the other to minimal methadone. In conclusion, INH retention time and completion rates were significantly improved by methadone treatment combined with observed INH, whether or not substance abuse counseling was provided. The results of this study indicate that methadone treatment offers clear public health benefits when it is used to deliver preventive medical services.

Epidemiological evidence of the spread of a Mycobacterium tuberculosis strain of the Beijing genotype on Gran Canaria Island

Molecular epidemiological studies suggest that particular Mycobacterium tuberculosis strains have an enhanced capacity to spread within a community. One strain, the Beijing genotype, has been associated with outbreaks in a number of communities throughout the world. IS6110 restriction fragment length polymorphism (RFLP) analysis was performed on M. tuberculosis isolates from 566 of the 721 patients (78.5%) diagnosed with tuberculosis (TB) on Gran Canaria Island from 1993 to 1996, as well as 35% of isolates from 1991-1992 (85 strains). RFLP identification of the family of strains of the Beijing genotype was confirmed by spoligotyping. Medical records of all patients were reviewed and epidemiological links were identified. Of 566 M. tuberculosis isolates from 1993 to 1996 with RFLP available, 72% belonged to clusters. The largest contained 75 cases and was caused by a strain of the Beijing genotype that was introduced to the island in 1993. It was found in 10 patients in 1993 (5.5%), 12 in 1994 (8.1%), 18 in 1995 (16.4%), and 35 in 1996 (27.1%). Epidemiological linkage was confirmed for 68% of cases. This study has demonstrated rapid dissemination of this strain of the Beijing genotype. This genotype might play an important role in the future of the worldwide tuberculosis epidemic.

Compliance with therapy in patients with chronic hepatitis C: associations with psychiatric symptoms, interpersonal problems, and mode of acquisition

Tolerance of interferon-a therapy for hepatitis C is often poor and medication is expensive. Compliance with diagnostic procedures and, even more important, with medical treatment is obviously critical to minimize the rate of dropouts and to maximize cost efficiency. Moreover, a good concordance with scheduled follow-ups is important for early recognition and treatment of interferon-associated side effects. Therefore, we investigated psychiatric symptoms, interpersonal problems, different modes of acquisition, and sociodemographic factors in HCV-infected patients as possible predictor variables of good versus poor compliance. In a longitudinal study, 74 patients with chronic hepatitis C (CHC) who fulfilled the criteria for treatment with interferon (IFN)-alpha-2b with or without ribavirin were investigated prospectively to identify those at risk for poor compliance during IFN medication. To assess predictive factors, we used both IIP-C (Inventory of Interpersonal Problems) and SCL-90-R (Symptom Check List 90 Items Revised) as psychometric instruments. Sociodemographic and somatic variables as well as compliance during IFN therapy were also evaluated. Poor compliance before or during medication was demonstrated by 23% (N = 17) of HCV patients. Sociodemographic factors and mode of acquisition, particularly former intravenous drug (IVD) abuse were not significantly linked with compliance. Logistic regression analysis demonstrated that the subgroup of patients with compliance problems was best identified by both pretherapeutic psychiatric symptoms and interpersonal problems. Predictive value was best and significant for anger-hostility (P = 0.009), intrusive (P = 0.014), depression (P = 0.015), and phobic anxiety (P = 0.049). Adopting this statistical prediction model, sensitivity was 47.1%, but specificity reached 98.3%. In total, 86.5% of cases were classified correctly. In situations of unclear indication for IFN therapy, psychological variables assessment of before the beginning of treatment may represent an additional decision-making factor.

[Outcome of treating initial tuberculosis in the area south of Seville in a 5-year period (1994-1998]

OBJECTIVE

To analyze the outcome of treating initial tuberculosis (ITB) in the hospital district south of Seville (Spain).

MATERIAL AND METHOD

A descriptive study of treatment outcome in cases of ITB in our district between 1 January 1994 and 31 December 1998. Outcome was classified according to World Health Organization guidelines:successful (S) potentially unsuccessful (PU), exitus (EX) and transferred out (T).Four hundred fifty-four patients (mean age 35 years) were enrolled; 22% were HIV+ and 21% were intravenous drug users (IVDU). Treatment was self-administered in all cases, with 98% being given the standard prescription of 6 or 9 drugs. No subsequent case history was found for 15 cases, such that outcome could not be assessed.

RESULTS

Of the 439 evaluable cases, outcome was S for 74% (326/439), PU for 16% (70/439), EX for 8% (36/439) and T for 6. Outcome for HIV + patients was poorer than for HIV- patients (S: 35/98 versus 291/341, p < 0.00005;PU: 40/98 versus 30/341, p < 0.00005), and the mortality rate of HIV+ patients was higher than that of HIV- patients (EX:18/98 versus 18/341, p < 0.0008). Among those classified PU,no cases of treatment failure were recorded and up to 78% (31/40)were cases of loss of follow-up or abandonment. The variable most closely related to PU was IVDU status (OR = 10.5, p < 0.00005).

CONCLUSION

a) Outcomes for the general population are acceptable. b)A marginal group has been identified as characterized by two variables, HIV+ and IVDU, which are the factors associated with poorer outcome of self-administered treatment, indicating that supervised treatment is advisable in cases where those factors are present.

Exogenous reinfection with tuberculosis on a European island with a moderate incidence of disease

The frequency and determinants of exogenous reinfection and of endogenous reactivation of tuberculosis in patients previously treated are poorly understood. In Gran Canaria Island, Spain, between 1991 and 1996, 962 tuberculosis cases were confirmed by culture. Drug susceptibility testing was performed on available bacterial isolates and IS6110-based RFLP genotyping was carried out. Twenty-three patients (2.4%) had two positive cultures separated by at least 12 mo, 18 of whom had bacterial DNA available for genotypic analysis. The initial and final isolates from eight (44%) were different genotypes, indicating exogenous reinfection. Six of them were retreated after cure and two retreated after default. Six were HIV seronegative and two were HIV seropositive. Endogenous reactivation was seen in the remaining 10 patients of whom eight were retreated after default and two after cure. Three of the eight (38%) being retreated after default developed multidrug resistance. One genotype was responsible for a second episode of tuberculosis in five cases, three exogenous reinfections and two endogenous reactivations. In the context of a moderate incidence of tuberculosis, exogenous reinfection is an important cause of TB recurrence, even in HIV-seronegative patients.

Directly observed therapy and treatment adherence

Direct observation of patients taking their medication is a strategy to improve completion rates for tuberculosis treatment, but the programmes to implement this approach consist of a complex array of inputs aimed at influencing adherence. Policy makers need a clear understanding of these inputs to succeed. We systematically identified and reviewed published reports of direct observation therapy (DOT) programmes and compared inputs with WHO's short-course DOT programme. DOT programmes frequently consist of more than the five elements of WHO's strategy, including incentives, tracing of defaulters, legal sanctions, patient-centred approaches, staff motivation, supervision, and additional external funds. Focusing on direct observation as a key factor in the promotion of adherence seems inappropriate. Multiple components might account for the success of DOT programmes, and WHO should make these explicit.

The outcome of tuberculosis treatment after implementation of the national tuberculosis control program in Saudi Arabia

BACKGROUND

Tuberculosis is an endemic disease in Saudi Arabia. Efforts to control this disease started in 1992 with the establishment of a National Tuberculosis Control Committee. Field application of a national tuberculosis control program (NTCP) was implemented in Riyadh in 1996 by the Ministry of Health, according to the guidelines of the World Health Organization (WHO). This study was aimed at evaluating the outcome of tuberculosis treatment before and after the implementation of this program.

PATIENTS AND METHODS

All active tuberculosis cases admitted and treated in the Sahary Chest Hospital, Riyadh, were studied. The outcome of treatment was evaluated, and a comparison was made between 1995 (before the implementation of the NTCP) and the years 1996-1998 (after implementation).

RESULTS

The total number of tuberculosis cases increased from 504 in 1995 to 726 (44%) in 1998. Cure rate increased from 24.4% to 36.2%, and the default rate decreased from 15% to only 1.2% during the same period. However, there was no change in the rate of completion of treatment, the rate of treatment failures, relapse or deaths.

CONCLUSION

Although the cure rate slightly improved and the default rate decreased, the overall outcome of the implementation of the national tuberculosis control program was not satisfactory. A recommendation for speedy application of directly observed therapy strategy (DOTS) is made to improve the control of tuberculosis in Saudi Arabia.

Fully intermittent dosing with drugs for tuberculosis

BACKGROUND

The number of people infected with tuberculosis continues to rise world-wide. Rifampicin-containing treatment regimens can achieve high cure rates. Intermittent drug treatment delivered in the community has the potential to improve adherence to treatment.

OBJECTIVES

The objective of this review was to compare the effectiveness of rifampicin-containing short-course chemotherapy regimens, given two or three times a week, with similar regimens given daily in patients with pulmonary tuberculosis.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Controlled Trials Register, Medline, and reference lists of articles. We contacted experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials of any multi-drug regimen containing rifampicin in patients with confirmed pulmonary tuberculosis. Treatment had to be given up to three times a week for up to nine months, with any initial daily dosing period not more than one month, and was compared to daily dosing throughout for the same period.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial eligibility and quality.

MAIN RESULTS

One trial involving 399 patients was included. The trial compared treatment three times per week with daily treatment for six months. There was no difference in cure rate (198 out of 199 people in the intermittent group compared to all 200 in the daily group), but 5 patients relapsed in the group receiving intermittent therapy compared to one in the group receiving the daily regimen.

REVIEWER'S CONCLUSIONS

There is not enough evidence to assess the equivalence of effect between fully intermittent, rifampicin-containing short-course chemotherapy and similar daily therapy in patients with pulmonary tuberculosis. Larger randomised studies are required to establish the effectiveness of fully intermittent, short-course chemotherapy.

Directly observed therapy for the treatment of tuberculosis--evidence based dosage guidelines

Tuberculosis is a communicable disease with public health implications and effective treatment is essential for control of the disease and prevention of the emergence of drug resistant strains. Drug therapy for this disease is well established and discussion now surrounds frequency of administration, duration of treatment and methods of improving compliance. Directly observed intermittent therapy of tuberculosis is supported by the World Health Authority and has become the standard of care in the U.S.A. Available dosage guidelines for directly observed therapy are only supported by limited data. A literature review of recent studies with clinical outcome measures was conducted. Following this review evidence based guidelines have been produced.

Twice-weekly, directly observed treatment for HIV-infected and uninfected tuberculosis patients: cohort study in rural South Africa

OBJECTIVE

To determine the effectiveness of twice-weekly directly observed therapy (DOT) for tuberculosis (TB) in HIV-infected and uninfected patients, irrespective of their previous treatment history. Also to determine the predictive value of 2-3 month smears on treatment outcome.

METHODS

Four hundred and sixteen new and 113 previously treated adults with culture positive pulmonary TB (58% HIV infected, 9% combined drug resistance) in Hlabisa, South Africa. Daily isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E) given in hospital (median 17 days), followed by HRZE twice a week to 2 months and HR twice a week to 6 months in the community.

RESULTS

Outcomes at 6 months among the 416 new patients were: transferred out 2%; interrupted treatment 17%; completed treatment 3%; failure 2%; and cured 71%. Outcomes were similar among HIV-infected and uninfected patients except for death (6 versus 2%; P = 0.03). Cure was frequent among adherent HIV-infected (97%; 95% CI 94-99%) and uninfected (96%; 95% CI 92-99%) new patients. Outcomes were similar among previously treated and new patients, except for death (11 versus 4%; P = 0.01), and cure among adherent previously treated patients 97% (95% CI 92-99%) was high. Smear results at 2 months did not predict the final outcome.

CONCLUSION

A twice-weekly rifampicin-containing drug regimen given under DOT cures most adherent patients irrespective of HIV status and previous treatment history. The 2 month smear may be safely omitted. Relapse rates need to be determined, and an improved system of keeping treatment interrupters on therapy is needed. Simplified TB treatment may aid implementation of the DOTS strategy in settings with high TB caseloads secondary to the HIV epidemic.

Evaluation of once-weekly therapy for tuberculosis using isoniazid plus rifamycins in the mouse aerosol infection model

Once-weekly therapy with combinations of isoniazid plus a rifamycin was tested in the mouse low-dose aerosol infection model against two strains of Mycobacterium tuberculosis. Combinations of isoniazid and rifalizil and isoniazid and rifapentine were both highly effective. These animal model data thus support the evaluation of these regimens under clinical conditions.

Chemotherapy and management of tuberculosis in the United Kingdom: recommendations 1998. Joint Tuberculosis Committee of the British Thoracic Society

BACKGROUND

The guidelines on chemotherapy and management of tuberculosis in the United Kingdom have been reviewed and updated.

METHODS

A subcommittee was appointed by the Joint Tuberculosis Committee (JTC) of the British Thoracic Society to revise the guidelines published in 1990 by the JTC. In preparing the revised guidelines the authors took account of new published evidence and graded the strength of evidence for their recommendations. The guidelines have been approved by the JTC and the Standards of Care Committee of the British Thoracic Society.

RECOMMENDATIONS

(1) Patients with tuberculosis should be notified. (2) In view of the rising incidence of drug resistance, bacteriological confirmation and drug susceptibility testing should be sought whenever possible. (3) A six month short course regimen, with four drugs in the initial phase, should be used for all forms of tuberculosis, except meningitis, in both adults and children. (4) The fourth drug (ethambutol) in the initial phase can be omitted in certain circumstances. (5) Treatment of all patients should be supervised by physicians with full training in the management of tuberculosis and with direct working access to tuberculosis nurse specialists or health visitors. (6) Advice is given on (a) management in special situations and patient groups, (b) drug interactions, and special precautions and pretreatment screening, (c) chemoprophylaxis for different groups, and (d) the management of single and multiple drug resistance. (7) Advice is given on follow up after treatment and the organisational framework for tuberculosis services. (8) The role of directly observed therapy is discussed. (9) The management of multidrug resistant tuberculosis is explained in outline: such patients should be managed by physicians with special experience and in close liaison with the Mycobacterium Reference Units, and in hospitals with appropriate isolation facilities. (10) Infection control and segregation for such patients and for patients with dual infection with human immunodeficiency virus (HIV) and tuberculosis are covered in an appendix.