THE RELATIONSHIP BETWEEN DELAYED OR INCOMPLETE TREATMENT AND ALL-CAUSE MORTALITY IN PATIENTS WITH TUBERCULOSIS

Objective.-To analyze the factors associated with survival in patients with pulmonary and extrapulmonary tuberculosis in New York City. Desi gn.-Observational study of a citywide cohort of tuberculosis cases. Se tting.-New York City, April 1991, before the strengthening of its cont rol program. Patients.-All 229 newly diagnosed cases of tuberculosis d ocumented by culture in April 1991. Most patients (74%) were male, and the median age was 37 years (range, 1-89 years). In all, 89% belonged to minority groups. Human immunodeficiency virus (HIV) infection was present in 50% and multidrug resistance in 7% of the cases. Twenty-one patients (9%) were not treated. Main Outcome Measures.-Follow-up info rmation was collected through the New York City tuberculosis registry; death from any cause was verified through the National Death Index. R esults.-Cumulative all-cause mortality by October 1994 was 44%; the me dian survival for those who died was 6.3 months (range, 0 days to 3 ye ars). The most important baseline predictors of mortality, adjusted fo r baseline clinical and demographic factors, were acquired immunodefic iency syndrome (AIDS) (91% vs 11% in HIV-seronegative patients; Cox re lative risk [RR], 7.8; 95% confidence interval [CI], 2.1-29.1), multid rug resistance (87% vs 39% in pansensitive cases; adjusted RR, 5.8; 95 % CI, 2.3-14.5), and lack of treatment (81% vs 40%; adjusted RR, 3.1; 95% CI, 1.0-9.7). Also, 11 of 13 HIV-infected patients who started tre atment after a 1-month delay died. Among 173 patients surviving the re commended treatment period, those who completed therapy (66%) had a lo wer subsequent mortality (20% vs 37%; RR, 0.5; 95% CI, 0.3-0.9). Concl usions.-Mortality from tuberculosis was high, even among patients with out multidrug resistance who were not known to be infected with HIV. M ost HIV-seropositive patients with delayed therapy died. Multidrug res istance predicted higher mortality, and treatment completion was assoc iated with improved subsequent patient survival.