Community-Based Therapy for Multidrug-Resistant Tuberculosis in Peru, Article Critique Example

In this highly-detailed article, first published in the prestigious New England Journal of Medicine in 2003, authors C. Mitnick, J. Bayona, E. Palacios, and twelve other specialists in infectious diseases with links to Harvard Medical School, the Harvard School of Public Health, and the departments of infectious diseases at several prominent hospitals in Lima, Peru, examine the prevalence of multidrug-resistant tuberculosis in a poor neighborhood in Lima, Peru, where the treatment of multidrug-resistant tuberculosis, a chronic granulomatous pulmonary infection caused by the bacillus Mycobacterium tuberculosis, has proven to be quite expensive, due to limited resources (i.e., trained infectious disease personnel and money), and the lack of infrastructure related to clinics that are capable of treating tuberculosis and similar infectious disorders (2003, p. 120).

The authors also point out that without treatment, multidrug-resistant strains of tuberculosis can easily spread throughout vulnerable populations, such as those living in poverty in the districts of Carabayllo, Comas, and Independencia, and that because of “unacceptably high rates of failure and relapse, new approaches to treatment” in Peru and other poor nations is required (2003, p. 120).

In order to explore the prevalence of multidrug-resistant tuberculosis in Lima, Peru, the authors utilized several different methods, such as a patient study (1996 to 1998) in which participants were “referred for evaluation for multidrug-resistant tuberculosis by Socios En Salud, a non-governmental organization working in northern Lima, Peru,” along with representatives from the Peruvian Ministry of Health and Lima-based infectious disease specialists. They also conducted bacteriologic studies on various strains of tuberculosis and drug susceptibility testing via samples taken from the participants (2003, p. 120).

In addition, the authors monitored the participants for any adverse effects related to taking a regimen of five specific drugs that have been shown to be effective against tuberculosis. After adhering to this regimen for more than three years, the results were that out of sixty-six patients, fifty-five “had probable cures at the completion of therapy,” five had withdrawn from treatment, one patient failed to respond to the treatment, and five died during the course of treatment (2003, pp. 121-122).

Overall, the authors appear to be satisfied with these results, for they discuss at length that this project in Lima, Peru, “yielded more probable cures than expected in patients whose prognosis was poor because of chronic, highly resistant tuberculosis,”  damage to tissues surrounding the lungs, and earlier exposure to other treatment regimens that most probably increased their drug resistance. Percentage-wise, the number of patients that responded favorably to treatment was “as high as any reported in a hospital setting” as of 2002 (2003, pp. 122-124).

Also, the authors mention several possible reasons for this type of outcome, such as the age of the participants which tended to be younger (under 30) than those in earlier projects, and the fact that all of the patients possessed fewer coexisting conditions that are generally associated with tuberculosis (2003, pp. 124-125). As to the future, the authors maintain that their DOTS-Plus model or Directly Observed Treatment Strategy can help to decrease current and future outbreaks of multidrug-resistant tuberculosis in Peru and other nations and that by “moving treatment into the community, it is possible, without compromising the quality of therapy, to lower costs and reduce the risk of spreading multidrug-resistant tuberculosis (2003, pp. 126-127). It should be mentioned that because this project was unique in the annals of infectious disease prevention, a literature review was not included.

The research topic for this article, being the prevalence of multidrug-resistant tuberculosis in Lima, Peru, has been deeply explored by other researchers, due to the fact that as a bacterium, tuberculosis continues to pose a great threat to the lives and well-being of poor populations on a global scale, such as in Southeast Asia (Vietnam, Cambodia, Myanmar, and China), and many countries that were once part of the Soviet Union, not to mention Sub-Saharan Africa.

According to the World Health Organization (WHO), projects and programs sponsored by the United States, Great Britain, France, and Germany, have attempted to eradicate tuberculosis over the last forty years, but due to the bacterium’s ability to resist many types of drugs, successful treatment only occurred about 50% of the time (Anti-Tuberculosis Drug Resistance in the World, 2005, p. 23). Thus, the project discussed in this article represents only one of many similar entities that have succeeded and failed at stopping the spread of multidrug-resistant tuberculosis.

The authors of this article also had great support related to their design and methodology. For example, all of the tuberculum samples from the participants were processed and studied by infectious disease specialists at the Sergio E. Bernales

Hospital in Lima; most of the testing was done by qualified staff members at the Massachusetts State Laboratory Institute and the National Jewish Medical and  Research Center in Denver, Colorado; and all of the participants were treated on an outpatient basis by a “team of specially trained community health workers, nurses, and physicians under the auspices of Socios En Salud (2003, pp. 120-121).

As to their statistical analysis, the authors utilized one of the best systems available, the Kaplan–Meier Estimates and the Cox Proportional Hazards Models which are employed by infectious disease clinics and research labs to analyze survival rates in a given population (Anti-Tuberculosis Drug Resistance in the World, 2005, p. 26), in this case, the sixty-six patients in the author’s project.

As previously mentioned, the results of this project were quite satisfactory, due to the fact that out of sixty-six patients/participants that completed the four month-long therapy regimen, 84% showed signs of improvement or had probable cures, while only 8% died during the regimen process. Certainly, this indicates that the drug therapy regimen set up by the authors and their collaborators was highly successful, thus giving it clinical support for future programs and projects based on decreasing or eliminating multidrug-resistant tuberculosis strains (2003, p. 122).

As discussed by the authors in their closing statements, this success will help make it possible for future “community-based therapy for multidrug-resistant tuberculosis” to be utilized in other countries ravaged by TB; it also “provides hope for the tens of millions of patients that are suffering from chronic infectious diseases” in other environments that do not possess an adequate health-based infrastructure or system of treatment (2003, p. 127).

The overall clinical implications of this project appears to hinge on the revelations found in Figure 1 (p. 124) that indicates the effectiveness of fifteen separate drugs utilized in the author’s project as treatment for tuberculosis. The lowest ranking drug in this chart is Clarithromycin (Biaxin), used to treat specific bacterial infections of the lungs, which was given to only one patient, due to his built-in resistance to other agents. The highest ranking is Cycloserine, an effective antibiotic that shows great promise in curing tuberculosis in the majority of patients (Anti-Tuberculosis Drug Resistance in the World, 2005, p. 145).

Therefore, due to the success of this latter drug, the findings of this project support the further use of Cycloserine for those afflicted with multidrug-resistant tuberculosis. It should also be noted that the success of this project may help to educate and/or inform infectious disease specialists of the effectiveness of this drug in treating patients with a history of multidrug-resistance to tuberculosis.

The general relevance of this project is that it throws a bright light on the future of treating tuberculosis with a regimen of drugs. As Mitnick, Bayona, Palacios, et al. point out in their conclusion, this project demonstrates that “community-based outpatient treatment of multidrug-resistant tuberculosis can yield high cure rates” and that the “early initiation of appropriate therapy can preserve susceptibility” or responses to drugs that ultimately will help to improve treatment outcomes (2003, p. 119).

In relation my own personal views on the seemingly pandemic existence of multidrug-resistant tuberculosis and how infectious disease specialists are currently attempting to treat and eradicate it, more studies are certainly required on a global basis and should be founded on the project initiated by the authors of this article. I also agree with what the World Health Organization has to say on the subject–“Clinical and in-field activities related to treating and curing multidrug-resistant tuberculosis must be fully encouraged by the medical community and by the leaders of those nations whose populations suffer and die on a daily basis from tuberculosis and other infectious diseases” (Anti-Tuberculosis Drug Resistance in the World, 2005, p. 155).

References

Anti-tuberculosis drug resistance in the world: Third global report. (2005). WHO/IUATLD Global Project on Anti-Tuberculosis Drug Resistance Surveillance. World Health Organization.

Mitnick, C., Bayona, J., Palacios, E., et al. (2003). Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. New England Journal of Medicine (348) 2, 119-128.