To establish risk factors influencing survival of patients with multidrug-resistant and extensively drug-resistant tuberculosis (MDR/XDRTB).
All MDR/XDRTB cases (n=1809) reported from 2002 to 2008 in Lithuania with a known outcome were included in the survival analysis.
Median survival for MDRTB and XDRTB patients was 4.1 (95% CI 3.7 to 4.4) and 2.9 (95% CI 2.2 to 3.9) years. In a multivariable analysis adjusting for other patient characteristics, the difference in survival between MDRTB and XDRTB patients was not significant (HR=1.29 (0.91 to 1.81)). Older age (HR=4.80 (3.16 to 7.29)) for 60+ vs <30 years, rural living (HR=1.20 (1.02 to 1.40)), alcohol use (HR=1.49 (1.13 to 1.96)) for alcoholic versus moderate use, unemployment (HR=1.79 (1.31 to 2.46)), lower education levels (HR=1.50 (1.08 to 2.07)) for primary level versus tertiary level, cavitary disease (HR=1.54 (1.29 to 1.83)) and being smear positive at the time of MDR/XDRTB diagnosis (HR=1.47 (1.19 to 1.82)) were associated with poorer survival. HIV positivity significantly affected survival (HR=3.44 (1.92 to 6.19)) for HIV positive versus HIV negative; HR=1.60 (1.28 to 2.01) for HIV not tested versus HIV negative). There was no difference in survival of patients who acquired MDR/XDRTB during treatment compared with patients with primary MDR/XDRTB (HR=1.01 (0.85 to 1.19)). Treatment with a second-line drug improved survival (HR=0.40 (0.34 to 0.47)). In a subgroup with genotyped TB strains, a Beijing family of strains was associated with poorer survival (HR=1.71 (1.19 to 2.47)).
Social factors, rural living, HIV infection and Beijing strain family impact on survival. Survival of MDR/XDRTB patients is short. Rapid drug resistance identification, early administration of appropriate treatment and achieving high cure rates, expansion of HIV testing and antiretroviral treatment are necessary for optimal management of MDR/XDRTB.
The Baltic States have consistently had one of the world's highest rates of drug resistant tuberculosis (TB) including multidrug- and extensively drug-resistant tuberculosis (MDR/XDRTB) despite an extensive tuberculosis control programmes.
Patients with TB in Lithuania show a relatively high mortality for unknown reasons.
The study analyses factors influencing survival of patients with MDR/XDRTB in Lithuania.
Patients with MDR/XDRTB show a poor survival regardless of HIV status, but there was no significant difference between MDRTB and XDRTB.
Patients infected with Beijing TB family strains and co-infected with HIV with underlying social problems have worse survival. However, only few TB patients are tested for HIV.
Addressing accompanying social and health problems (eg, alcohol dependency), access to care in rural settings and expansion of HIV testing and antiretroviral treatment are necessary to improve survival.
Strength and limitations of the study
This is the first national study to analyse 7 years of national surveillance data covering a large cohort of MDR/XDRTB patients.
The study demonstrates the value of long-term survival cohorts, as well as pointing to the absence of comparable UK data.
Limitations: limited data on HIV status (due to the low HIV testing coverage in the early years of the TB programme) and limited genotyping data for the XDRTB isolates.