Limited success and high attrition in the 9-month all-oral regimen for MDR-TB: Evidence from a tertiary care setting in Indonesia.

BACKGROUND

The WHO endorses the 9-month all-oral regimen for MDR-TB as a preferred therapeutic option due to its shorter duration, lower cost, and improved adherence compared to the 18-24-month more extended longer regimen. While studies supporting the WHO recommendation report high success rates, in real-world settings, particularly in Indonesian tertiary hospitals, this regimen is often prematurely switched to a longer course. Moreover, success rates for those who continue the 9-month regimen remain relatively low.

OBJECTIVES

This study investigates factors contributing to the premature switch from the 9-month regimen to a longer regimen and evaluates therapeutic outcomes for patients who remain on the 9-month regimen.

METHODS

A retrospective observational study was conducted involving 52 MDR-TB patients who initiated the 9-month all-oral regimen at Dr. Soetomo Hospital, Indonesia, between 2022 and 2024. Reasons for switching to a longer regimen were documented, and therapeutic outcomes, including cure rates, mortality, and loss to follow-up, were assessed among patients who continued the 9-month regimen.

RESULTS

Of 52 patients, 34 (65,38 %) were switched due to resistance to high-dose isoniazid, pyrazinamide, and levofloxacin. Severe nausea and vomiting prompted switching in 13 (25 %), while allergy accounted for 3 cases (5,77 %). Less common reasons included optic neuropathy (1 case, 1,92 %) and increased serum creatinine (1 case, 1,92 %). No switches occurred due to prolonged QT interval or hepatitis. Among the remaining 40 patients, 28 (70 %) were cured, 3 (7.5 %) died, and 9 (22.5 %) were lost to follow-up.

CONCLUSION

Premature switching from the 9-month all oral regimen is mainly due to drug resistance and adverse effects. Patients who remained on the regimen generally had favorable outcomes, though some challenges persist. These findings emphasize the need for timely drug susceptibility testing and better management of adverse effects to optimize the regimen's effectiveness in real-world settings.