NONCOMPLIANCE WITH DIRECTLY OBSERVED THERAPY FOR TUBERCULOSIS - EPIDEMIOLOGY AND EFFECT ON THE OUTCOME OF TREATMENT

Study objectives: To describe the epidemiology and clinical consequenc es of noncompliance with directly observed therapy (DOT) for treatment of tuberculosis, Design: Retrospective review. Setting: An urban tube rculosis control program that: emphasizes DOT, Patients: All patients treated with outpatient DOT from 1984 to 1994. Measurements and result s: We defined noncompliance as follows: (1) missing greater than or eq ual to 2 consecutive weeks of DOT; (2) prolongation of treatment >38 d ays due to sporadic missed doses; or (3) incarceration for presenting a threat to public health, Poor outcomes of therapy were defined as a microbiologic or clinical failure of initial therapy, relapse, or deat h due to tuberculosis, Fifty-two of 294 patients (18%) who received ou tpatient DOT fulfilled one or more criteria for noncompliance. Using m ultivariate logistic regression, risk factors for noncompliance were a lcohol abuse (odds ratio, 3.0; 95% confidence interval, 1.2 to 7.5; p= 0.02) and homelessness (odds ratio, 3.2; 95% confidence interval, 1.5 to 7.2; p=0.004), Noncompliant patients had poor outcomes from the ini tial course of therapy more often than compliant patients: 17 of 52 (3 2.7%) vs 8 of 242 (3.3%); relative risk was 0.9; 95% confidence interv al was 4.5 to 21.7 (p<0.001), Conclusions: ln an urban tuberculosis co ntrol program, noncompliance with DOT was common and was closely assoc iated with alcoholism and homelessness, Noncompliance was associated w ith a 10-fold increase in the occurrence of poor outcomes from treatme nt and accounted for most treatment failures. Innovative programs are needed to deal with alcoholism and homelessness in patients with tuber culosis.