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Abstract
High Prevalence and Mortality from Extensively-Drug Resistant (XDR) TB in TB/HIV Coinfected Patients in Rural South Africa
N.R. Gandhi1, A. Moll2, R. Pawinski3, A.W. Sturm4, U. Lalloo3, K. Zeller5, J. Andrews6, G. Friedland6
1Emory University School of Medicine, Division of Infectious Diseases, Atlanta, United States, 2Church of Scotland Hospital and Philanjalo, Tugela Ferry, KwaZulu Natal, South Africa, 3Nelson R. Mandela School of Medicine, Enhancing Care Initiative, Durban, South Africa, 4Nelson R. Mandela School of Medicine, Department of Medical Microbiology, Durban, South Africa, 5Brown Medical School, Department of Family Medicine, Providence, United States, 6Yale University School of Medicine, Yale AIDS Program, New Haven, United States
Background: In a rural district in KwaZulu Natal, South Africa, where the TB/HIV coinfection rate is greater than 80%, antiretroviral therapy (ARV) has significantly reduced mortality. Of the remaining deaths, 67% have been documented to be due to multi-drug resistant (MDR) TB. We sought to determine the extent and consequences of MDR TB among patients in this district.
Methods: Surveillance with sputum culture and drug susceptibility testing was performed for patients with known or suspected TB in a rural district hospital. Spoligotyping was performed on isolates resistant to all tested TB drugs (isoniazid, rifampin, ethambutol, streptomycin, ciprofloxacin, kanamycin).
Results: Between January 2005 and March 2006, sputum collected from 1540 patients revealed that 536 (35%) patients were culture positive for M.tb. Of these, 221 (41%) had MDR TB, and 53 (24% of MDR isolates, 10% of all positive cultures) had resistance to all first and second line drugs tested (XDR TB). Spoligotyping revealed 90% of XDR TB patients were infected with a genetically similar strain. 52 of 53 (98%) XDR TB patients have died; the median survival after sputum collection was 25 days (range: 11–136). All 47 XDR TB patients with known HIV status, were HIV positive. Only 34% of patients were previously treated for TB and 56% had been previously hospitalized.
Conclusions: Increased surveillance in rural South Africa revealed a markedly greater MDR TB prevalence than previously recognized, with evidence of recent nosocomial and community transmission of XDR TB in HIV coinfected patients. The convergence of the TB/HIV epidemic with MDR and XDR TB in resource poor settings is a deadly threat to gains in survival achieved by TB DOTS and ARV therapy.
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