Community-based Short-Course Treatment of Pulmonary Tuberculosis in a Developing Nation: Initial Report of an Eight-Month, Largely Intermittent Regimen in a Population with a High Prevalence of Drug Resistance

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Abstract
A community-based tuberculosis case-finding and short-course chemotherapy program was conducted in a suburb of Manila (the Philippines) and featured 1 month of daily isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA) followed by 7 months of twice-weekly, high dose, directly observed INH + EMB + PZA. Church-affiliated lay workers obtained 1,990 sputum specimens from subjects who complained of chronic cough or wasting symptoms; 207 of the specimens were positive on Ziehl-Neelsen smears. On culture, 176 yielded a significant growth of Mycobacterium tuberculosis. Of these 176 patients, 144 were selected to enter the study; 10 were lost because of withdrawal or death and four (2.7%) because of drug toxicity. This left 130 patients who were followed long-term. Remarkably, 80% (104) were initially shedding drug-resistant organisms; 26% (34) were resistant to one drug, 30% (40) were resistant to two drugs, and 24% (30) were resistant to three or more drugs. Responses to therapy corresponded closely to the extent of drug resistance: 80% (48 of 60) of patients with drug-susceptible or single resistance had a favorable outcome; 43% (28 of 65) were resistant to two or three drugs, and 0% (0 of 5) of those were resistant to four or more drugs. Notable findings of this study were the success of a community-based program in conducting prolonged, directly observed treatment, the unexpectedly high prevalence of multiple-drug resistant organisms in this population, and the inadequacy of INH + PZA + EMB during the continuation phase of therapy in this setting.