The International Journal of Mycobacteriology

: 2022  |  Volume : 11  |  Issue : 2  |  Page : 226--227

Factors associated with treatment outcomes in drug-resistant tuberculosis

Oki Nugraha Putra1, Affan Yuniar Nur Hidayatullah2,  
1 Department of Clinical Pharmacy, Study Program of Pharmacy, Hang Tuah University, Surabaya, Indonesia
2 Department of Pharmacy, Apothecary Program, Brawijaya University, Malang, Indonesia

Correspondence Address:
Oki Nugraha Putra
Arief Rahman Hakim 150, Surabaya, East Java

How to cite this article:
Putra ON, Nur Hidayatullah AY. Factors associated with treatment outcomes in drug-resistant tuberculosis.Int J Mycobacteriol 2022;11:226-227

How to cite this URL:
Putra ON, Nur Hidayatullah AY. Factors associated with treatment outcomes in drug-resistant tuberculosis. Int J Mycobacteriol [serial online] 2022 [cited 2022 Aug 15 ];11:226-227
Available from:

Full Text

Dear Editor,

We appreciated a recent study by Johnson et al., published in the International Journal of Tuberculosis, reported predictors of successful and unsuccessful outcomes in patients with drug-resistant tuberculosis (DR-TB).[1] DR-TB is a significant problem in treating tuberculosis, characterized by low success rates and high treatment failure rates. However, data in several countries may differ depending on the patient's sociodemographic condition and resistance profile. The study by Johnson et al. enrolled multidrug-resistant-TB (MDR-TB) patients between 2015 and 2018. According to the WHO 2016, DR-TB therapy uses aminoglycoside injections in shorter and longer regimens.[2] The latest guidelines from WHO in 2020 state that aminoglycoside injections are no longer used for DR-TB treatment and are replaced entirely with an oral regimen consisting of five drugs and the inclusion of bedaquiline and/or delamanid in the regimen.[3] The high rate of treatment failure in DR-TB patients using aminoglycosides injection is because of their ototoxicity and low level of patient compliance.

A recent study by Soeroto et al. reported that in patients with MDR/rifampicin-resistant (RR) TB in West Java, Indonesia, who underwent short-term treatment with aminoglycoside injection, the success rate was 64.5%.[4] MDR/RR-TB patients with malnutrition had a history of previous TB treatment, and those with sputum conversion for more than 2 months were significantly associated with treatment failure. On the other hand, the success rate was 50% in patients receiving long-term regimens. Age, sex, body mass index, history of TB treatment, time to sputum conversion, HIV, chronic kidney disease (CKD), and lung cavity were significant predictors of treatment outcomes.[5] The percentage of success rate reported by Johnson et al.[1] is much lower at 7.1% compared to the study by Soeroto et al.[4],[5] One factor contributing to the low success rate is a loss to follow-up (LFTU). A long treatment of DR-TB, side effects of antitubercular drugs, psychosocial and economic conditions contribute to the high rate of LFTU. Negative attitudes toward treatment, limitation of social support, dissatisfaction with health services, and restriction of economic status were correlated with increased LFTU.[6]

However, a study by Johnson et al. did not compare the difference in success rates in patients with MDR TB/extensively drug-resistant (XDR) TB and non-MDR-TB as stated in the demographic data. Furthermore, multivariate analysis showed that retreated TB cases and kidney disorders were associated with unsuccessful treatment outcomes.[1] CKD is one of the factors closely related to the failure of therapy for MDR-TB patients. A study by Ruzangi et al. reported that in patients with CKD, the incidence of TB was higher (14,63%) compared to those without CKD (9.89%).[7] As is known, uremia in CKD patients will cause a weakened immune system, making the patient more susceptible to TB infection. Another study by Sapriadi et al. reported that there was a significant association between a history of TB treatment and antituberculosis drug resistance.[8]

MDR-TB and XDR-TB have been reported to have different treatment outcomes. The study by Machmud et al., analyzing the difference in treatment outcomes in MDR-TB and XDR-TB patients, found that poor treatment outcomes (death) were more common in XDR-TB patients than in MDR-TB, 16% and 11.5%, respectively.[9] Compared to MDR-TB, XDR TB is defined as resistance to one of the fluoroquinolones and at least resistance to one of the class A drugs (bedaquiline and/or clofazimine).[3]

The inclusion of bedaquiline and/or delamanid in the management of DR-TB increases the cure rate and patient compliance.[10] Unfortunately, data regarding the effectiveness of bedaquiline and/or delamanid in Indonesia and the factors that influence the success of therapy are not yet available. The limited use of bedaquiline and/or delamanid in Drug Resistant Tuberculosis patients in Indonesia is caused by concerns about side effects in prolonging the QT interval. However, QT prolongation is more common in hypokalemia, hypoalbuminemia, and the elderly.[11] This is a challenge for future research regarding the effectiveness of bedaquiline and delamanid in the clinical outcomes and the factors influencing them. In conclusion, in order to reduce LFTU, DR-TB patients with a high risk of treatment failure should be closely monitored, increase patient education, drug availability, and health facility services.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Johnson JM, Mohapatra AK, Velladath SU, Shettigar KS. Predictors of treatment outcomes in drug resistant tuberculosis-observational retrospective study. Int J Mycobacteriol 2022;11:38-46.
2World Health Organization. WHO Treatment Guidelines for Drug-Resistant Tuberculosis. World Health Organization; 2016.
3World Health Organization. WHO Consolidated Guidelines on Tuberculosis. Module 4, Treatment: Drug-Resistant Tuberculosis Treatment. World Health Organization; 2020.
4Soeroto AY, Nurhayati RD, Purwiga A, Lestari BW, Pratiwi C, Santoso P, et al. Factors associated with treatment outcome of MDR/RR-TB patients treated with shorter injectable based regimen in West Java Indonesia. PLoS One 2022;17:e0263304.
5Soeroto AY, Pratiwi C, Santoso P, Lestari BW. Factors affecting outcome of longer regimen multidrug-resistant tuberculosis treatment in West Java Indonesia: A retrospective cohort study. PLoS One 2021;16:e0246284.
6Soedarsono S, Mertaniasih NM, Kusmiati T, Permatasari A, Juliasih NN, Hadi C, et al. Determinant factors for loss to follow-up in drug-resistant tuberculosis patients: The importance of psycho-social and economic aspects. BMC Pulm Med 2021;21:360.
7Ruzangi J, Iwagami M, Smeeth L, Mangtani P, Nitsch D. The association between chronic kidney disease and tuberculosis; a comparative cohort study in England. BMC Nephrol 2020;21:420.
8Sapriadi S, Syahridha S. Factor related to anti-tuberculosis drug resistency on pulmonary tuberculosis patients in Labuang Baji Hospital Makassar. Indonesian J Trop Infect Dis 2018;7:40-4.
9Machmud PB, Gayatri D, Ronoatmodjo S. A survival analysis of successful and poor treatment outcome among patients with drug-resistant tuberculosis and the associated factors: A retrospective cohort study. Acta Med Indones 2021;53:184-93.
10Nasiri MJ, Zangiabadian M, Arabpour E, Amini S, Khalili F, Centis R, et al. Delamanid-containing regimens and multidrug-resistant tuberculosis: A systematic review and meta-analysis. Int J Infect Dis 2022:S1201-9712 (22)00125-4. doi:10.1016/j.ijid.2022.02.043. Online ahead of print.
11Hewison C, Khan U, Bastard M, Lachenal N, Coutisson S, Osso E, et al. Safety of treatment regimens containing bedaquiline and delamanid in the endTB cohort. Clin Infect Dis 2022:ciac019. doi:10.1093/cid/ciac019. Online ahead of print.