PITFALLS IN THE CARE OF PATIENTS WITH TUBERCULOSIS - COMMON ERRORS AND THEIR ASSOCIATION WITH THE ACQUISITION OF DRUG-RESISTANCE

Objective.-To determine, among a group of patients with multidrug-resi stant pulmonary tuberculosis, whether there had been management practi ces that deviated from established guidelines, and whether these decis ions were associated with the acquisition of multidrug resistance and adverse medical sequelae. Design.-Case series. Setting.-Referral cente r. Patients.-All patients with pulmonary tuberculosis admitted to the National Jewish Center for Immunology and Respiratory Medicine in 1989 through 1990. Interventions.-The records of all patients referred to this institution for the treatment of tuberculosis in 1989 through 199 0 were reviewed to ascertain the nature of management decisions that m ight have been associated with the acquisition of drug resistance. Mai n Outcome Measures.-Standards of practice as defined by the American T horacic Society, the Centers for Disease Control and Prevention, and t he American College of Chest Physicians were compared with these manag ement decisions to determine whether ''errors'' had been made, resulti ng in treatment failure and the development of acquired drug resistanc e. Results.-Among the 35 study patients, errors were detected in the m anagement decisions in 28; there was an average of 3.93 errors per pat ient. The most common errors were the addition of a single drug to a f ailing regimen, failure to identify preexisting or acquired drug resis tance, initiation of an inadequate primary regimen, failure to identif y and address noncompliance, and inappropriate isoniazid preventive th erapy. The multidrug resistance acquired through the errors resulted i n prolonged hospitalizations, treatment with more toxic drugs, and hig h-risk resectional surgery. The costs for this ''salvage therapy'' wer e extraordinary, averaging $180 000 per patient. Conclusions.-Aggressi ve professional education, tighter control on the provisions of care f or tuberculosis patients, and the committing of additional resources t o tuberculosis control programs are vital in improving the care of tub erculosis patients and limiting the development of acquired drug resis tance.