Multidisciplinary management of difficult-to-treat drug resistant tuberculosis: a review of cases presented to the national consilium in Uganda

Abstract

Background Patients with drug resistant tuberculosis (DR-TB) with comorbidities and drug toxicities are difficult to treat. Guidelines recommend such patients to be managed in consultation with a multidisciplinary team of experts (the “TB consilium”) to optimise treatment regimens. We describe characteristics and treatment outcomes of DR-TB cases presented to the national DR-TB consilium in Uganda between 2013 and 2019. Methods We performed a secondary analysis of data from a nation-wide retrospective cohort of DR-TB patients with poor prognostic indicators in Uganda. Patients had a treatment outcome documented between 2013 and 2019. Characteristics and treatment outcomes were compared between cases reviewed by the consilium with those that were not reviewed. Results Of 1,122 DR-TB cases, 189 (16.8%) cases from 16 treatment sites were reviewed by the consilium, of whom 86 (45.5%) were reviewed more than once. The most frequent inquiries (N = 308) from DR-TB treatment sites were construction of a treatment regimen (38.6%) and management of side effects (24.0%) while the most frequent consilium recommendations (N = 408) were a DR-TB regimen (21.7%) and “observation while on current regimen” (16.6%). Among the cases reviewed, 152 (80.4%) were from facilities other than the national referral hospital, 113 (61.1%) were aged ≥ 35 years, 72 (40.9%) were unemployed, and 26 (31.0%) had defaulted antiretroviral therapy. Additionally, 141 (90.4%) had hepatic injury, 55 (91.7%) had bilateral hearing loss, 20 (4.8%) had psychiatric symptoms and 14 (17.7%) had abnormal baseline systolic blood pressure. Resistance to second-line drugs (SLDs) was observed among 9 (4.8%) cases while 13 (6.9%) cases had previous exposure to SLDs. Bedaquiline (13.2%, n = 25), clofazimine (28.6%, n = 54), high-dose isoniazid (22.8%, n = 43) and linezolid (6.7%, n = 13) were more frequently prescribed among cases reviewed by the consilium than those not reviewed. Treatment success was observed among 126 (66.7%) cases reviewed. Conclusion Cases reviewed by the consilium had several comorbidities, drug toxicities and a low treatment success rate. Consilia are important “gatekeepers” for new and repurposed drugs. There is need to build capacity of lower health facilities to construct DR-TB regimens and manage adverse effects.

Early culture conversion is a poor marker of treatment outcome among people with HIV and drug‐resistant TB

“…At the treatment centre, a standardised DRTB treatment regimen was initiated according to national guidelines [18][19][20][21]. The regimens were individualised according to the baseline DST, drug toxicities, treatment failure, and other considerations as decided by the national DRTB expert panel [22].…”

Why does it take so long? The reasons behind Drug Resistant -Tuberculosis (DR-TB) treatment delay in Uganda

“…The causes of this DR-TB are multifactorial and are fueled by inappropriate TB treatment and management which is complex [11], thus requires a multidisciplinary team of healthcare workers. Worse still, it is very expensive compared to susceptible TB, it is treated with many drugs for a long period of 11-20 months, which causes many side effects [12,13]. Furthermore, DR-TB is reported to result into a lot of household catastrophic costs; the Uganda National TB 2020 catastrophic survey, shows that 53% of TB affected households experienced catastrophic costs above 20% of their annual expenditure averaging USD 3722 for DR-TB patients compared to USD 396 for Drug sensitive TB patients [14].…”