Introduction
Tuberculosis continues to be an important health problem especially in developing countries like India. The emergence of drug resistant tuberculosis is posing a major threat in the control of Tuberculosis. The estimated multi drug resistant and Rifampicin – resistant tuberculosis cases around the world was 4,84,000 worldwide. India had estimated multi drug resistant tuberculosis / Rifampicin resistant - tuberculosis cases of 1,30,0001. The factors including inadequate chemotherapy, poor adherence to treatment, treatment failure, prior treatment, pulmonary cavity tuberculosis, diabetes and Human immunodeficiency virus infection are known to progress the drug adherence2, 3.
The available study shows that, the epidemiological characteristics and clinical profiles of the patients with the multidrug resistant tuberculosis varies from one region to another region. The knowledge of these characteristic are essential to develop the treatment strategies and can help the government to establish the policies4, 5 . Hence this study was taken up to assess the clinical and epidemiological characteristics of patients with multidrug resistant tuberculosis.
Material and Methods
A case control study was conducted in the Chest and TB outpatient department of Basaveshwara Medical College and Hospital, Chitradurga in order to study the epidemiological characteristics and clinical characteristics of Multi drug resistant tuberculosis cases. A total of 30 cases confirmed as Multidrug resistant tuberculosis patients constituted the cases. For the purpose of the study, MDR TB was defined as “A multi-drug resistant tuberculosis suspect who is sputum culture positive and whose TB is due to Mycobacterium tuberculosis that are resistant in-vitro to at least isoniazid and rifampicin (the culture and DST result being from an RNTCP accredited laboratory)”. The patients with non-drug resistant tuberculosis constituted the control group. About 60 age and sex matched controls were taken in to the study. The cases and controls satisfying the cases definition and started with multi drug resistant tuberculosis treatment regimen as per drug-susceptibility test results were included in to the study. The patients who refused to give consent were excluded from the study.
A total of 30 cases and 60 controls were examined thoroughly for the epidemiological and clinical characteristics. A detailed history including details of cough, expectoration, history of ATT & follow up at period intervals was taken. A standardized proforma was administered for both cases and controls. The data thus obtained was compiled and analyzed using Statistical Package for Social Services (SPSS vs 20) using appropriate statistical tests.
Results
Table 1
Distribution of the study group according to epidemiologic characteristics
This study had shown that, about 53.3% of the study subjects belonged to 21 – 30 years. Males outnumbered females. About 50% of the study subjects belonged to rural areas. Majority of cases were educated up to primary school and 41.7% of the controls were educated up to secondary school. Majority of the cases and controls were Hindu by religion and nuclear family and married. Most of cases were farmers and housewives and majority of the controls were housewives.
Table 2
Distribution of the study group according to symptoms
Cough was present in 53.3% of the cases followed by shortness of breath (23.3%), expectoration (23.3%), fever (20.0%), haemoptysis (20%), chest pain (20.0%) and wheezing (16.7%). Controls had symptoms in lesser extent than cases.
Table 3
Distribution of study group according to quantity of haemoptysis
| Quantity of hemoptysis | Cases N (%) | Controls N (%) |
| Absent | 24 (80.0) | 57 (95.0) |
| Less than 100 ml | 2 (6.7) | 2 (3.3) |
| 100 – 200 ml | 2 (6.7) | 1 (1.7) |
| More than 200 ml | 2 (6.7) | 0 |
The haemoptysis was less than 100 ml in 6.7% of the cases, 100 – 200 ml in 6.7% of the cases and more than 200 ml in 6.7% of the cases. The controls had less than 100 ml of the haemoptysis in 3.3% of the cases and 100 – 200 ml in 1.7% of the cases.
Table 4
Distribution of study group according to comorbidities
The diabetes mellitus was present as co morbidity in 23.3% of the cases and 20% of the controls, kidney disease in 13.3% of the cases and 18.3% of the controls, previous surgery in 10%, steroid intake in 1.7% of the controls. HIV was present in 33.3% of the cases and 6.7% of the controls.
Table 5
Distribution of study group according to habits
| Habits | Cases N (%) | Controls N (%) |
| Never smoker | 9 (30.0) | 14 (23.3) |
| Former smoker | 15 (50.0) | 32 (20.0) |
| Current smoker | 6 (20.0) | 14 (23.3) |
| Alcoholic | 12 (40.0) | 21 (35.0) |
| Tobacco chewer | 5 (16.7) | 9 (15.0) |
About 50% of the cases were former smokers and 40% were alcoholics and 16.7% were tobacco chewers. Among controls, 20% were former smokers, 35.0% were alcoholics and tobacco chewers.
Table 6
Treatment aspects of MDR TB
The treatment was regular in 30% of the cases and 71.7% of the controls. The missed doses were more than 40 in 46.3% of the cases. About 60% of the cases were compliant with the drugs.
Discussion
This study was mainly undertaken to assess the epidemiological and clinical factors associated with multidrug resistant tuberculosis. Most of the victims of the multidrug resistant tuberculosis belonged to earning age group and males outnumbered females. Most of the cases were from rural areas and were with low education. Hindus and married people were common in occurrence of multiple drug resistant tuberculosis. The results of this study with respect to age were similar to the studies conducted by Mendes et al.,6, Coelho et al.,7 and Micheletti et al.,8.
Cough was the common symptom in cases followed by shortness of breath, expectoration, fever, haemoptysis, chest pain and wheezing. Controls had symptoms in lesser extent than cases in this study. In a study by Kim et al., he had observed the severe clinical condition was found in 44% of the multi-drug resistant tuberculosis cases. About 34% of the cases had haemoptysis. The haemoptysis was less than 100 ml in 6.7% of the cases, 100 – 200 ml in 6.7% of the cases and more than 200 ml in 6.7% of the cases. Majority of the cases had grade 4 or 5 breathlessness and had high grade intermittent fever compared to controls8.
The diabetes mellitus and HIV were the common co-morbidities among the cases. In a study, Kim et al had observed that diabetes mellitus was the co-morbidity in 18.7% and 17.1% of the extensively drug resistant tuberculosis and multi drug resistant tuberculosis patients respectively. None of the patients with HIV had extensively drug resistant tuberculosis or multi drug resistant tuberculosis8.
About 50% of the cases were former smokers and 40% were alcoholics and 16.7% were tobacco chewers in this study. A study by Balaji et al., had shown that the multi-drug resistant TB had a negative association with MDR–TB9. In a study, Marahatta had observed that smoking is associated with the Isoniazid resistance10. In a study in Delhi, smoking was associated factor with 40.8%, 37.7% & 50% of the multi-drug resistant tuberculosis, Pre xtensively drug resistant tuberculosis & extensively drug resistant tuberculosis respectively11.
The treatment was regular in 30% and missed doses were more than 40 in 46.3% of the cases. About 60% of the cases were compliant with the drugs. Noncompliance favors development of further resistance to other drugs. Poor compliance to drugs is an important risk factor for development of acquired drug resistance in Tuberculosis Patients11.
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