Predictors of Death during Tuberculosis Treatment in TB/HIV Co-Infected Patients in Malaysia

Abstract

BackgroundMortality among TB/HIV co-infected patients is still high particularly in developing countries. This study aimed to determine the predictors of death in TB/HIV co-infected patients during TB treatment.MethodsWe reviewed medical records at the time of TB diagnosis and subsequent follow-up of all newly registered TB patients with HIV co-infection at TB clinics in the Institute of Respiratory Medicine and three public hospitals in the Klang Valley between January 2010 and September 2010. We reviewed these medical records again twelve months after their initial diagnosis to determine treatment outcomes and survival. We analysed using Kaplan-Meier and conducted multivariate Cox proportional hazards analysis to identify predictors of death during TB treatment in TB/HIV co-infected patients.ResultsOf the 227 patients studied, 53 (23.3%) had died at the end of the study with 40% of deaths within two months of TB diagnosis. Survival at 2, 6 and 12 months after initiating TB treatment were 90.7%, 82.8% and 78.8% respectively. After adjusting for other factors, death in TB/HIV co-infected patients was associated with being Malay (aHR 4.48; 95%CI 1.73-11.64), CD4 T-lymphocytes count < 200 cells/µl (aHR 3.89; 95% CI 1.20-12.63), three or more opportunistic infections (aHR 3.61; 95% CI 1.04-12.55), not receiving antiretroviral therapy (aHR 3.21; 95% CI 1.76-5.85) and increase per 103 total white blood cell count per microliter (aHR 1.12; 95% CI 1.05-1.20)ConclusionTB/HIV co-infected patients had a high case fatality rate during TB treatment. Initiation of antiretroviral therapy in these patients can improve survival by restoring immune function and preventing opportunistic infections.

Survival and prognostic factors in HIV-infected adults treated with Antiretroviral Therapy in a Malaysian referral hospital: A retrospective cohort study

“…A Malaysian study involving HIV/TB patients looked further into the association of types of tuberculosis with mortality. When compared to extrapulmonary TB both smear positive pulmonary TB and smear negative pulmonary TB were not prognostic for a higher mortality [24]. The same result was reported in a study in Myanmar reporting that pulmonary TB was not found to be a predictor for death based on multiple Cox proportional hazards regression [22].…”

Tuberculosis Comorbidity with Communicable and Noncommunicable Diseases

“…There are reports for and against an association between diabetes and drug-resistant tuberculosis (Dooley and Chaisson 2009), with possible explanations including delayed clearance resulting in routine switching to a twodrug regimen in patients who are still culturepositive or lowered rifampicin levels in diabetes patients (Nijland et al 2006). Among TB patients, having diabetes is linked with a significant increase in the risk of death Ismail and Bulgiba 2013). Very little of the available data comes from sub-Saharan African populations, where diabetes prevalence will increase over the next decade (Dooley and Chaisson 2009) and where TB and diabetes treatment decisions for significant numbers of patients will have to frequently accommodate antiretroviral therapy, which itself is associated with increased risk of TB (Marais et al 2013).…”

A prediction rule to stratify mortality risk of patients with pulmonary tuberculosis

“…It will be interesting, in future, to compare TReAT with each of these scores and analyse their relative performance and applicability to different settings. In the present work, the fatal outcome was determined until 6 months after diagnosis, which is supported by several studies, including clinical trials [29][30][31], and contemplates the minimum duration of the standard multidrug treatment. Late mortality related to TB was previously described to stabilize after 6-months of treatment [30].…”

“…In the present work, the fatal outcome was determined until 6 months after diagnosis, which is supported by several studies, including clinical trials [29][30][31], and contemplates the minimum duration of the standard multidrug treatment. Late mortality related to TB was previously described to stabilize after 6-months of treatment [30]. Nevertheless, patients died more frequently during the first 30 days after diagnosis, which did not appear to be related with diagnostic delay, since fatal cases usually had shorter time of symptoms compared to survivors (Table 1).…”