Noncompliance with directly observed therapy for tuberculosis: epidemiology and effect on the outcome of treatment

Study objectives: To describe the epidemiology and clinical consequences of noncompliance with directly observed therapy (DOT) for treatment of tuberculosis. Design: Retrospective review. Setting: An urban tuberculosis control program that emphasizes DOT. Patients: All patients treated with outpatient DOT from 1984 to 1994. Measurements and results: We defined noncompliance as follows: (1) missing [is greater than or equal to] 2 consecutive weeks of DOT; (2) prolongation of treatment [is greater than] 30 days 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 death due to tuberculosis. Fifty-two of 294 patients (18%) who received outpatient DOT fulfilled one or more criteria for noncompliance. Using multivariate logistic regression, risk factors for noncompliance were alcohol 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 initial course of therapy more often than compliant patients: 17 of 52 (32.7%) vs 8 of 242 (3.3%); relative risk was 9.9; 95% confidence interval was 4.5 to 21.7 (p [is less than] 0.001). Conclusions: In an urban tuberculosis control program, noncompliance with DOT was common and was closely associated with alcoholism and homelessness. Noncompliance was associated with a 10-fold increase in the occurrence of poor outcomes from treatment and accounted for most treatment failures. Innovative programs are needed to deal with alcoholism and homelessness in patients with tuberculosis. (CHEST 1997, 111:1168-73) Key words adherence; alcoholism; directly observed therapy; homelessness; noncompliance; tuberculosis Abbreviations: DOT = directly observed therapy
Noncompliance with self-administered multidrug tuberculosis treatment regimens is common and is the most important cause of failure of initial therapy and relapse.[1-6] Noncompliance may also result in acquired drug resistance,[6] [...]