High mortality in adults hospitalized for active tuberculosis in a low HIV prevalence setting

• Published in: PloS one Vol. 9; no. 3; p. e92077
• Main Authors: Lui, Grace, Wong, Rity Y K, Li, Florence, Lee, May K P, Lai, Raymond W M, Li, Timothy C M, Kam, Joseph K M, Lee, Nelson
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 18.03.2014; Public Library of Science (PLoS)
• Subjects: Acquired immune deficiency syndrome; Adults; Aged; AIDS; Analysis; Antitubercular Agents - therapeutic use; Biology and Life Sciences; Coinfection; Culture; Delayed Diagnosis; Diagnosis; Female; Fluoroquinolones; Fluoroquinolones - therapeutic use; Histology; HIV; HIV Infections - diagnosis; HIV Infections - drug therapy; HIV Infections - mortality; HIV Infections - virology; Hospital Mortality; Hospital patients; Hospitals; Human immunodeficiency virus; Humans; Hypoxemia; Infections; Infectious diseases; Lung diseases; Male; Malignancy; Medical diagnosis; Medical research; Medicine; Medicine and Health Sciences; Microscopy; Middle Aged; Mortality; Multidrug resistance; Mycobacterium tuberculosis; Mycobacterium tuberculosis - isolation & purification; Patients; Population; Research and Analysis Methods; Respiratory tract diseases; Retrospective Studies; Smear; Social Sciences; Survival Analysis; Systematic review; Tuberculosis; Tuberculosis, Central Nervous System - diagnosis; Tuberculosis, Central Nervous System - drug therapy; Tuberculosis, Central Nervous System - microbiology; Tuberculosis, Central Nervous System - mortality; Tuberculosis, Lymph Node - diagnosis; Tuberculosis, Lymph Node - drug therapy; Tuberculosis, Lymph Node - microbiology; Tuberculosis, Lymph Node - mortality; Tuberculosis, Multidrug-Resistant - diagnosis; Tuberculosis, Multidrug-Resistant - drug therapy; Tuberculosis, Multidrug-Resistant - microbiology; Tuberculosis, Multidrug-Resistant - mortality; Tuberculosis, Pleural - diagnosis; Tuberculosis, Pleural - drug therapy; Tuberculosis, Pleural - microbiology; Tuberculosis, Pleural - mortality; Tuberculosis, Pulmonary - diagnosis; Tuberculosis, Pulmonary - drug therapy; Tuberculosis, Pulmonary - microbiology; Tuberculosis, Pulmonary - mortality; Tuberculosis, Urogenital - diagnosis; Tuberculosis, Urogenital - drug therapy; Tuberculosis, Urogenital - microbiology; Tuberculosis, Urogenital - mortality; Hong Kong China; China
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0092077

This study aims to evaluate the outcomes of adults hospitalized for tuberculosis in a higher-income region with low HIV prevalence. 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 M. tuberculosis, (2) positive M. tuberculosis 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. 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). 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.