Long-term outcomes in South African patients who have extremely-drug resistant tuberculosis (XDR-TB) are “poor” immaterial of HIV status, notes a paper published on January 17 in The Lancet . Despite treatment outcomes being poor, “substantial number” of XDR-TB patients who were still infected were discharged from hospitals in spite of failing treatment. With the median survival period of these patients being nearly 20 months, the patients are “likely” to spread drug-resistant TB in the community, notes the study by Elize Pietersen et al from the University of Cape Town, South Africa.

“Many patients … 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,” the authors write.

According to them, a third of discharged patients were smear-positive and hence continued to be infected with XDR-TB, suggesting “high transmission potential.” Of the 45 patients who were discharged from the hospital into the community, 19 (42 per cent) continued to be XDR-TB culture-positive.

They cite lack of bed space in designated tuberculosis hospitals, scarce alternative long-term residential and palliative care facilities, and inadequate resources to support proper home-based care when appropriate as reasons for discharging the patients into the community.

The situation is likely to be similar in countries like India where XDR-TB and totally drug-resistant TB are present, they warn. “The findings we have outlined are likely to be relevant in several settings where XDR or totally drug-resistant tuberculosis has been described, such as … India,” they note.

Even with a multidrug regimen that includes capreomycin and fairly good adherence, the long-term treatment outcomes in XDR-TB patients are “poor.”

A cohort of 107 patients with XDR-TB was followed up between March 2008 and August 2012. At the end of two years, only 17 patients (16 per cent) had favourable outcomes (treatment cure or completion), while 25 patients (23 per cent) failed treatment. Forty-nine patients died and seven defaulted on treatment.

At the end of five years, only 12 patients (11 per cent) had favourable outcomes (treatment cure or completion), while 11 patients (10 per cent) had failed treatment.

Published in The Hindu on January 17, 2014