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October 16, 1996

The Relationship Between Delayed or Incomplete Treatment and All-Cause Mortality in Patients With Tuberculosis

Author Affiliations

From the Division of General Medicine, College of Physicians and Surgeons, Columbia University, New York, NY (Dr Pablos-Méndez); Bureau of Tuberculosis Control, New York City Department of Health (Drs Pablos-Méndez, Sterling, and Frieden); Keesler Medical Center, Keesler Air Force Base, Miss (Dr Sterling); and Centers for Disease Control and Prevention, Atlanta, Ga (Dr Frieden).

JAMA. 1996;276(15):1223-1228. doi:10.1001/jama.1996.03540150025026

Objective.  —To analyze the factors associated with survival in patients with pulmonary and extrapulmonary tuberculosis in New York City.

Design.  —Observational study of a citywide cohort of tuberculosis cases.

Setting.  —New York City, April 1991, before the strengthening of its control program.

Patients.  —All 229 newly diagnosed cases of tuberculosis documented by culture in April 1991. Most patients (74%) were male, and the median age was 37 years (range, 1-89 years). In all, 89% belonged to minority groups. Human immunodeficiency virus (HIV) infection was present in 50% and multidrug resistance in 7% of the cases. Twenty-one patients (9%) were not treated.

Main Outcome Measures.  —Follow-up information was collected through the New York City tuberculosis registry; death from any cause was verified through the National Death Index.

Results.  —Cumulative all-cause mortality by October 1994 was 44%; the median survival for those who died was 6.3 months (range, 0 days to 3 years). The most important baseline predictors of mortality, adjusted for baseline clinical and demographic factors, were acquired immunodeficiency syndrome (AIDS) (91% vs 11% in HIV-seronegative patients; Cox relative risk [RR], 7.8; 95% confidence interval [CI], 2.1-29.1), multidrug resistance (87% vs 39% in pansensitive cases; adjusted RR, 5.8; 95% CI, 2.3-14.5), and lack of treatment (81% vs 40%; adjusted RR, 3.1; 95% CI, 1.0-9.7). Also, 11 of 13 HIV-infected patients who started treatment after a 1-month delay died. Among 173 patients surviving the recommended treatment period, those who completed therapy (66%) had a lower subsequent mortality (20% vs 37%; RR, 0.5; 95% CI, 0.3-0.9).

Conclusions.  —Mortality from tuberculosis was high, even among patients without multidrug resistance who were not known to be infected with HIV. Most HIV-seropositive patients with delayed therapy died. Multidrug resistance predicted higher mortality, and treatment completion was associated with improved subsequent patient survival.