Date Published: January 26, 2017
Publisher: Public Library of Science
Author(s): Meng-Yu Chen, Yi-Chun Lo, Wan-Chin Chen, Kwei-Feng Wang, Pei-Chun Chan, Joan A Caylà.
Recurrence after successful treatment for multidrug-resistant tuberculosis (MDR-TB) is challenging because of limited retreatment options. This study aimed to determine rates and predictors of MDR-TB recurrence after successful treatment in Taiwan. Recurrence rates were analyzed by time from treatment completion in 295 M DR-TB patients in a national cohort. Factors associated with MDR-TB recurrence were examined using a multivariate Cox regression analysis. Ten (3%) patients experienced MDR-TB recurrence during a median follow-up of 4.8 years. The overall recurrence rate was 0.6 cases per 1000 person-months. Cavitation on chest radiography was an independent predictor of recurrence (adjusted hazard ratio [aHR] = 6.3; 95% CI, 1.2–34). When the analysis was restricted to 215 patients (73%) tested for second-line drug susceptibility, cavitation (aHR = 10.2; 95% CI, 1.2–89) and resistance patterns of extensively drug-resistant TB (XDR-TB) or pre-XDR-TB (aHR = 7.3; 95% CI, 1.2–44) were associated with increased risk of MDR-TB recurrence. In Taiwan, MDR-TB patients with cavitary lesions and resistance patterns of XDR-TB or pre-XDR-TB are at the highest risk of recurrence. These have important implications for MDR-TB programs aiming to optimize post-treatment follow-up and early detection of recurrent MDR-TB.
Multidrug-resistant tuberculosis (MDR-TB), defined as tuberculosis caused by a strain of Mycobacterium tuberculosis resistant to at least isoniazid and rifampin, remains a global concern. Over the past several years, a growing number of studies have shown that recurrence after successful treatment of MDR-TB was not uncommon [1–15] (S1 Appendix). Reported recurrence rates vary worldwide from 0% after 2 years of follow-up [5,13,15] to 8.5% after 8 years of follow-up . Managing patients with MDR-TB recurrence represents a challenge for medical and public health professionals because of limited retreatment options and continuing threat to close contacts.
There were 375 MDR-TB patients registered at the TMTC between May 2007 and December 2010, of whom 295 achieved treatment success (249 were cured, and 46 completed treatment) (Fig 1). These 295 patients with successful outcomes comprised our cohort of analysis. The characteristics of the 295 patients were summarized in Table 1. Among these 295 patients, 228 (77%) were male. The median age at the initiation of MDR-TB treatment was 48 years (interquartile range [IQR], 37–59 years). Of the 191 patients who underwent HIV testing, four (2.1%) were HIV positive. Patient classification in the registry showed that 62% had history of previous anti-TB treatment (relapse, treated after loss to follow-up, or treated after failure). Patients with previous treatment history were more likely to have cavitation on the chest radiograph compared to newly diagnosed patients (p = 0.005).
In this nationwide study with a median duration of follow-up of 4.8 years, 10 (3.4%) of the 295 MDR-TB patients experienced MDR-TB recurrence. Incidences of recurrence in the first 12 months and between months 13–24 of follow-up were lower than or comparable to those reported from the MDR-TB program in Peru [1,2] and Russia . Such low rates of recurrence—either in terms of recurrence proportion or incidence rate—demonstrate the effectiveness of our MDR-TB program, characterized by government-organized, hospital-initiated, and patient-centered care .