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Case study of resistant tuberculosis health and social care essay

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Assess: The patient, Mr. Kahn, 66 year-old ex-smoker, was recently diagnosed to have multiple drug resistant TB, resistant to rifampicin and isoniazid, which are useful 1st line drugs in chemotherapy of tuberculosis. He experienced chronic cough for 2 months with production of yellowish sputum. Chest x-rays showed right upper lobe fibrosis, consistent with pulmonary TB. He was sputum positive and was required to admit to the isolation ward. Initial treatment using the standard agents HREZ was not satisfactory and culture results revealed multiple drug resistant TB. MDR-TB generally has a poorer outcome than non-resistant TB, and second-lined TB drugs need to be added to increase the effectiveness of the treatment, but are more expensive, with much more side effects. One of the standard drugs commonly used in Hong Kong is ofloxacin. However, a newer generation of fluoroquinolones, levofloxacin was used in this patient. Ask: The clinical questions for this case are as follow, P Patient 66 year old male patientEx-smokerMultiple resistant TB resistant to isoniazid and rifampicinI Intervention levofloxacin in combination with other drugs to treatMRD-TBC Comparison Using ofloxacin, and older generation of fluoroquinolonesO Outcome Does this improve the overall treatment outcome, such asthe success rate of treatment?

Acquire:

Pubmed Database was used as a search engineSearch items include: Multiple drug resistant tuberculosis, levofloxacin and ofloxacinCombining all the items yields only 10 resultsThe following paper is selected: Yew WW, Chan CK, Leung CC, Chau CH, Tam CM, Wong PC, Lee J. Comparative roles of levofloxacin and ofloxacin in the treatment of multidrug-resistant tuberculosis: preliminary results of a retrospective study from Hong Kong. Chest. 2003 Oct; 124(4): 1476-81. This paper is a retrograde study conducted in Hong Kong. Although the statistical level of evidence is not high, this is understandable as clinical randomized controlled trial might not be feasible due to ethical constraints. Also other papers are not suitable as most of them are only in vitro trials which are not suitable to apply in human yet. One result include a meta- analysis trying to study the effects of different fluoroquinolones on treating MDR-TB, but the meta-analysis consists a total of more than 100 pages which are difficult to extract relevant information for appraisal.

Appraise

This paper is a case control studies ( retrograde analysis) which aim at comparing levofloxacin and ofloxacin in the treatment of multidrug resistant tuberculosis. It is internally valid despite the fact of low statistical evidence. The sample size is not large with only 99 patients in total due the low prevalence of MDR-TB in Hong Kong. The study also tried to eliminate bias by firstly comparing demographic, clinical and bacteriologic characters among the 2 groups which are similar. The recall bias is also reduced, as the information of the patient is obtained directly from medical reports rather than interviewing real patients, thus the percentage of patients receiving each treatment and the treatment outcome can be more accurately obtained. This improves the validity of the study. Methods of the studyThe data of the study is form the medical record of Grantham Hospital, as well as chest clinics under the department of Health in Hong Kong form July 1997 to December 2000. A total of 99 patients, who were seronegative for HIV, were selected. The laboratory testing of drug susceptibility was also recorded and compared, particularly the proportion of each group which was confirmed to be ofloxacin resistant. The paper also compared the other treatment regimens, such as aminoglycosides used in each group, as well as the dose of levofloxacin and levofloxacin, which shows no statistically significant difference. This eliminated the effect of other drugs or dosage which may alter the treatment effects and cause errors. The treatment effect was defined by whether the patient can meet the requirement of successful bacteriological conversion of culture from positive to negative for at least 6 consecutive months during the therapy and on cessation. Statistical analysisThe data was analyzed using the t test ( For numerical variables) and Chi-square test for categoric variables . Mantel-Haenszel common odd ratio was used to test the significance of the result differences. P value < 0. 05 is considered to be significant. Other variables such as demographical factors, age, sex, adherence, etc were analyzed by using the multiple regression method to examine the various impacts on the outcome. The efficacies of the 2 drugs were further compared by their success rate stratified with the no. of adverse factors present. ResultThe treatment success rate in the group using levofloxacin was significantly higher than the group using ofloxacin. The success rate of the group with levofloxacin is 90. 0% overall compared with 79. 7% in ofloxacin group. The success rate is also higher even if the TB is not susceptible to ofloxacin in the laboratory culture (78. 6% vs 45. 5%), Mantel-Haenszel common odd ratio= 4, p= 0. 049. ImplicationThe result shows that using levofloxacin in combination with other drugs achieve better success rate when compared with using ofloxacin. This also matches with the in vitro trials, which suggested more active action of levofloxacin against Mycobacterium tuberculosis. Using levofloxacin can achieve better treatment outcome with no difference on side effects comparing the older agent ofloxacin statistically. However, when interpreting the result, some bias or errors may actually affect the internal validity of the study. There can be possible selection bias since not all case during the stated period is selected and the paper did not mention any selection criteria. Also those data did not include patients with treatment failure due to treatment intolerance or hypersensitivity. This also affects the validity of the result.

Apply

This result is applicable to my patient since this study is conducted in Hong Kong, which therefore a good external validity. Also the results match with in vitro studies. Despite the fact of low level of evidence, the recall bias is greatly reduced with the collection of data by medical report. Careful analysis using regression models eliminates the effect of confounders. The comparison of other demographical, clinical factors, treatment regimen etc shows no significant difference, further improve the reliability of the study. Therefore, the patient, using levofloxacin, instead of ofloxacin in treating MDR-TB can significantly increase the success rate of treatment statistically. However, whether it is clinically useful remain unsure as the effect of treatment varies from individuals.

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