High Mortality in Adults Hospitalized for Active Tuberculosis in a Low HIV Prevalence Setting

<div><p>Background</p><p>This study aims to evaluate the outcomes of adults hospitalized for tuberculosis in a higher-income region with low HIV prevalence.</p><p>Methods</p><p>A retrospective cohort study was conducted on all adults hospitalized for pulmonary and/or extrapulmonary tuberculosis in an acute-care hospital in Hong Kong during a two-year period. Microscopy and solid-medium culture were routinely performed. The diagnosis of tuberculosis was made by: (1) positive culture of <i>M. tuberculosis</i>, (2) positive <i>M. tuberculosis</i> PCR result, (3) histology findings of tuberculosis infection, and/or (4) typical clinico-radiological manifestations of tuberculosis which resolved after anti-TB treatment, in the absence of alternative diagnoses. Time to treatment (‘early’, started during initial admission; ‘late’, subsequent periods), reasons for delay, and short- and long-term survival were analyzed.</p><p>Results</p><p>Altogether 349 patients were studied [median(IQR) age 62(48–77) years; non-HIV immunocompromised conditions 36.7%; HIV/AIDS 2.0%]. 57.9%, 16.3%, and 25.8% had pulmonary, extrapulmonary, and pulmonary-extrapulmonary tuberculosis respectively. 58.2% was smear-negative; 0.6% multidrug-resistant. 43.4% developed hypoxemia. Crude 90-day and 1-year all-cause mortality was 13.8% and 24.1% respectively. 57.6% and 35.8% received ‘early’ and ‘late’ treatment respectively, latter mostly culture-guided [median(IQR) intervals, 5(3–9) vs. 43(25–61) days]. Diagnosis was unknown before death in 6.6%. Smear-negativity, malignancy, chronic lung diseases, and prior exposure to fluoroquinolones (adjusted-OR 10.6, 95%CI 1.3–85.2) delayed diagnosis of tuberculosis. Failure to receive ‘early’ treatment independently predicted higher mortality (Cox-model, adjusted-HR 1.8, 95%CI 1.1–3.0).</p><p>Conclusions</p><p>Mortality of hospitalized tuberculosis patients is high. Newer approaches incorporating methods for rapid diagnosis and initiation of anti-tuberculous treatment are urgently required to improve outcomes.</p></div

Characteristics and outcomes of patients who received early diagnosis and treatment during the initial hospital admission, versus those who were diagnosed late (± treatment).

1<p>Altogether, 125 patients received ‘late’ treatment and 23 remained undiagnosed before death thus received no anti-TB treatment (see text). Comparisons between those who had received ‘early’ treatment and those who died before TB diagnosis were described in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0092077#pone.0092077.s003" target="_blank">Table S3</a>.</p>2<p>Basis for initiating ‘early’ anti-TB treatment (n = 201): positive-smear 93 (46.3%), positive PCR 8 (4.0%), positive culture 6 (3.0%), histological findings 35 (17.4%), typical clinico-radiological manifestations 59 (29.4%); ‘late’ treatment (n = 125): positive-smear 10 (8.0%), positive PCR 6 (4.8%), positive culture 86 (68.8%), histological findings 12 (9.6%), clinico-radiological manifestations 11 (8.8%).</p>3<p>Received fluoroquinolones prior to the diagnosis of TB. Levofloxacin was used in 15 cases, and ciprofloxacin in 2 cases.</p

Survival of patients with smear-negative tuberculosis (n = 203), according to time of initiation of anti-TB treatment.

<p>Patients who received late (thin solid line)(HR 3.65, 95%CI 1.07–12.40; p = 0.039) or no anti-TB treatment (dotted line)(HR 104.22, 95%CI 24.59–441.66; p<0.001) were shown to have significantly lower survival than those who received early treatment (thick solid line)(reference), as shown in the final Cox proportional hazards model, adjusted for demographics, immunocompromised conditions (HR 3.95, 95%CI 1.85–8.44; p<0.001) and supplemental oxygen requirement (HR 1.98, 95%CI 1.02–3.85; p = 0.043). Basis for initiating ‘early’ anti-TB treatment (n = 75): positive PCR 5 (6.7%), positive culture 5 (6.7%; liquid-medium, 3), histological findings 22 (29.3%), typical clinico-radiological manifestations 43 (57.3%).</p