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September 10, 1997, Vol 278, No. 10 >
ARTICLE | September 10, 1997

Trends in Drug-Resistant Tuberculosis in the United States, 1993-1996 FREE

Marisa Moore, MD; Ida M. Onorato, MD; Eugene McCray, MD; Kenneth G. Castro, MD
[+] Author Affiliations

Reprints: Marisa Moore, MD, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Mailstop E-10, Atlanta, GA 30333.


JAMA. 1997;278(10):833-837. doi:10.1001/jama.1997.03550100059039
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References

Context.  —With the resurgence of tuberculosis (TB) disease in the late 1980s and early 1990s in the United States, multidrug-resistant (MDR) TB emerged as a serious challenge to TB control. In response, the Centers for Disease Control and Prevention in 1993 added drug susceptibility test results to the information collected for the national surveillance system to monitor trends in drug resistance.

Objective.  —To determine the extent of drug-resistant tuberculosis (TB) in the United States.

Design.  —Descriptive analysis of TB surveillance data.

Study Population.  —Patients reported to the national TB surveillance system as confirmed TB cases with culture-positive disease from 1993 through 1996 by the 50 states, New York City, and the District of Columbia (DC).

Main Outcome Measure.  —Percentage of case patients with culture-positive disease whose isolates are resistant to specific anti-TB drugs.

Results.  —Overall resistance to at least isoniazid was 8.4%; rifampin, 3.0%; both isoniazid and rifampin (ie, MDR TB), 2.2%; pyrazinamide, 3.0%; streptomycin, 6.2%; and ethambutol hydrochloride, 2.2%. Rates of resistance were significantly higher for case patients with a prior TB episode. Among those without prior TB, isoniazid resistance of 4% or more was found in 41 states, New York City, and DC. A total of 1457 MDR TB cases were reported from 42 states, New York City, and DC; however, 38% were reported from New York City. Rates of isoniazid and streptomycin resistance were higher for cases among US-born compared with foreign-born patients, but rates of rifampin resistance and MDR TB were similar. Among US-born patients, resistance to first-line drugs, particularly rifampin monoresistance, was significantly higher among those with human immunodeficiency virus (HIV) infection.

Conclusions.  —Compared with recent US surveys in 1991 and 1992, isoniazid resistance has remained relatively stable. In addition, the percentage of MDR TB has decreased, although the national trend was significantly influenced by the marked decrease in New York City. Foreign-born and HIV-positive patients and those with prior TB have higher rates of resistance. The widespread extent of isoniazid resistance confirms the need for drug susceptibility testing to guide optimal treatment of patients with culture-positive disease.

REFERENCES

1 +
Centers for Disease Control.  Strategic plan for the elimination of tuberculosis in the United States . MMWR Morb Mortal Wkly Rep . 1989;;38:1-25.
2 +
Centers for Disease Control.  National action plan to combat multidrug-resistant tuberculosis . MMWR Morb Mortal Wkly Rep . 1992;;41( (RR-11) ):1-30.
3 +
Mahmoudi A, Iseman MD.  Pitfalls in the care of patients with tuberculosis . JAMA . 1993;;270:65-68.
4 +
Edlin BR, Tokars JI, Grieco MH, et al.  An out-break of multidrug-resistant tuberculosis among hospitalized patients with the acquired immunodeficiency syndrome . N Engl J Med . 1992;;326:1514-1521.
5 +
Frieden TR, Fujiwara PI, Washko RM, et al.  Tuberculosis in New York City: turning the tide . N Engl J Med . 1995;;333:229-233.
6 +
Chaulet P, Boulahbal F, Grosset J.  Surveillance of drug resistance for tuberculosis control: why and how? Tuberc Lung Dis . 1995;;76:487-492.
7 +
Doster B, Caras GJ, Snider DE.  A continuing survey of primary drug resistance in tuberculosis, 1961-1968 . Am Rev Respir Dis . 1976;;113:419-425.
8 +
Centers for Disease Control.  Primary resistance to antituberculous drugs—United States . MMWR Morb Mortal Wkly Rep . 1983;;32:521-523.
9 +
Kopanoff DE, Kilburn JO, Glassroth JL, et al.  A continuing survey of tuberculosis primary drug resistance in the United States . Am Rev Respir Dis . 1978;;118:835-842.
10 +
Snider DE, Cauthen GM, Farer LS, et al.  Drug resistant tuberculosis . Am Rev Respir Dis . 1991;;144:732.
11 +
Bloch AB, Cauthen GM, Onorato IM, et al.  Nationwide survey of drug-resistant tuberculosis in the United States . JAMA . 1994;;271:665-671.
12 +
Bloch AB, Cauthen GM, Onorato IM, et al. Drug resistant tuberculosis (TB) trends in the US. Presented at the 1994 American Lung Association/ American Thoracic Society International Conference; May 21-25, 1994; Boston, Mass.
13 +
Bloch AB, Onorato IM, Ihle WW, et al.  Expanded tuberculosis surveillance in the United States . Public Health Rep . 1996;;111:26-31.
14 +
Centers for Disease Control and Prevention.  Laboratory practices for diagnosis of tuberculosis—United States, 1994 . MMWR Morb Mortal Wkly Rep . 1995;;44:587-591.
15 +
Burwen DR, Bloch AB, Griffin LD, et al.  National trends in the concurrence of tuberculosis and acquired immunodeficiency syndrome . Arch Intern Med . 1995;;155:1281-1286.
16 +
Small PM, Shafer RW, Hopewell PC, et al.  Exogenous reinfection with multidrug-resistant Mycobacterium tuberculosis in patients with advanced HIV infection . N Engl J Med . 1993;;328:1137-1144.
17 +
Nardell E, McInis B, Thomas B, Weichaas S.  Exogenous reinfectionwith tuberculosis in a shelter for the homeless . N Engl J Med . 1986;;315:1570-1575.
18 +
American Thoracic Society and the Centers for Disease Control and Prevention.  Treatment of tuberculosis and tuberculosis infection in adults and children . Am J Respir Crit Care Med . 1994;;149:1359-1374.
19 +
Frieden TR, Sterling T, Pablos-Mendez A, et al.  The emergence of drug-resistant tuberculosis in New York City . N Engl J Med . 1993;;328:521-526.
20 +
Nolan CM, Williams DL, Cave MD, et al.  Evolution of rifampin resistance in human immunodeficiency virus—associated tuberculosis . Am J Respir Crit Care Med . 1995;;152:1067-1071.
21 +
Bradford WZ, Martin JN, Reingold AL, et al.  The changing epidemiology of acquired drug-resistant tuberculosis in San Francisco, USA . Lancet . 1996;;348:928-931.
22 +
Whitney CG, Ridzon R, Paul W.  Epidemiology of rifampin-resistant tuberculosis (RRTB), Chicago . Am J Respir Crit Care Med . 1996;;153:A492.
23 +
Ridzon R, Taylor J, Kelly M, et al.  Increased risk of rifampin mono-resistant tuberculosis in human immunodeficiency virus infection . Am J Respir Crit Care Med . 1996;;153:A493. Abstract.
24 +
Barnes PF.  The influence of epidemiologic factors on drug resistance rates in tuberculosis . Am Rev Respir Dis . 1987;;136:325-328.
25 +
Riley LW, Arathoon E, Loverde VD.  The epidemiologic patterns of drug-resistant Mycobacterium tuberculosis: a community-based study . Am Rev Respir Dis . 1989;;139:1282-1285.
26 +
Centers for Disease Control.  Drug resistance among Indochinese refugees with tuberculosis . MMWR Morb Mortal Wkly Rep . 1981;;30:273-275.
27 +
Laszlo A, de Kantor IN.  A random sample survey of initial drug resistance among tuberculosis cases in Latin America . Bull World Health Organ . 1994;;72:603-610.
28 +
Cohn DL, Bustreo F, Raviglione MC.  Drug-resistant tuberculosis . Clin Infect Dis . 1997;;24( (suppl 1) ):S121-S130.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

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1 +
Centers for Disease Control.  Strategic plan for the elimination of tuberculosis in the United States . MMWR Morb Mortal Wkly Rep . 1989;;38:1-25.
2 +
Centers for Disease Control.  National action plan to combat multidrug-resistant tuberculosis . MMWR Morb Mortal Wkly Rep . 1992;;41( (RR-11) ):1-30.
3 +
Mahmoudi A, Iseman MD.  Pitfalls in the care of patients with tuberculosis . JAMA . 1993;;270:65-68.
4 +
Edlin BR, Tokars JI, Grieco MH, et al.  An out-break of multidrug-resistant tuberculosis among hospitalized patients with the acquired immunodeficiency syndrome . N Engl J Med . 1992;;326:1514-1521.
5 +
Frieden TR, Fujiwara PI, Washko RM, et al.  Tuberculosis in New York City: turning the tide . N Engl J Med . 1995;;333:229-233.
6 +
Chaulet P, Boulahbal F, Grosset J.  Surveillance of drug resistance for tuberculosis control: why and how? Tuberc Lung Dis . 1995;;76:487-492.
7 +
Doster B, Caras GJ, Snider DE.  A continuing survey of primary drug resistance in tuberculosis, 1961-1968 . Am Rev Respir Dis . 1976;;113:419-425.
8 +
Centers for Disease Control.  Primary resistance to antituberculous drugs—United States . MMWR Morb Mortal Wkly Rep . 1983;;32:521-523.
9 +
Kopanoff DE, Kilburn JO, Glassroth JL, et al.  A continuing survey of tuberculosis primary drug resistance in the United States . Am Rev Respir Dis . 1978;;118:835-842.
10 +
Snider DE, Cauthen GM, Farer LS, et al.  Drug resistant tuberculosis . Am Rev Respir Dis . 1991;;144:732.
11 +
Bloch AB, Cauthen GM, Onorato IM, et al.  Nationwide survey of drug-resistant tuberculosis in the United States . JAMA . 1994;;271:665-671.
12 +
Bloch AB, Cauthen GM, Onorato IM, et al. Drug resistant tuberculosis (TB) trends in the US. Presented at the 1994 American Lung Association/ American Thoracic Society International Conference; May 21-25, 1994; Boston, Mass.
13 +
Bloch AB, Onorato IM, Ihle WW, et al.  Expanded tuberculosis surveillance in the United States . Public Health Rep . 1996;;111:26-31.
14 +
Centers for Disease Control and Prevention.  Laboratory practices for diagnosis of tuberculosis—United States, 1994 . MMWR Morb Mortal Wkly Rep . 1995;;44:587-591.
15 +
Burwen DR, Bloch AB, Griffin LD, et al.  National trends in the concurrence of tuberculosis and acquired immunodeficiency syndrome . Arch Intern Med . 1995;;155:1281-1286.
16 +
Small PM, Shafer RW, Hopewell PC, et al.  Exogenous reinfection with multidrug-resistant Mycobacterium tuberculosis in patients with advanced HIV infection . N Engl J Med . 1993;;328:1137-1144.
17 +
Nardell E, McInis B, Thomas B, Weichaas S.  Exogenous reinfectionwith tuberculosis in a shelter for the homeless . N Engl J Med . 1986;;315:1570-1575.
18 +
American Thoracic Society and the Centers for Disease Control and Prevention.  Treatment of tuberculosis and tuberculosis infection in adults and children . Am J Respir Crit Care Med . 1994;;149:1359-1374.
19 +
Frieden TR, Sterling T, Pablos-Mendez A, et al.  The emergence of drug-resistant tuberculosis in New York City . N Engl J Med . 1993;;328:521-526.
20 +
Nolan CM, Williams DL, Cave MD, et al.  Evolution of rifampin resistance in human immunodeficiency virus—associated tuberculosis . Am J Respir Crit Care Med . 1995;;152:1067-1071.
21 +
Bradford WZ, Martin JN, Reingold AL, et al.  The changing epidemiology of acquired drug-resistant tuberculosis in San Francisco, USA . Lancet . 1996;;348:928-931.
22 +
Whitney CG, Ridzon R, Paul W.  Epidemiology of rifampin-resistant tuberculosis (RRTB), Chicago . Am J Respir Crit Care Med . 1996;;153:A492.
23 +
Ridzon R, Taylor J, Kelly M, et al.  Increased risk of rifampin mono-resistant tuberculosis in human immunodeficiency virus infection . Am J Respir Crit Care Med . 1996;;153:A493. Abstract.
24 +
Barnes PF.  The influence of epidemiologic factors on drug resistance rates in tuberculosis . Am Rev Respir Dis . 1987;;136:325-328.
25 +
Riley LW, Arathoon E, Loverde VD.  The epidemiologic patterns of drug-resistant Mycobacterium tuberculosis: a community-based study . Am Rev Respir Dis . 1989;;139:1282-1285.
26 +
Centers for Disease Control.  Drug resistance among Indochinese refugees with tuberculosis . MMWR Morb Mortal Wkly Rep . 1981;;30:273-275.
27 +
Laszlo A, de Kantor IN.  A random sample survey of initial drug resistance among tuberculosis cases in Latin America . Bull World Health Organ . 1994;;72:603-610.
28 +
Cohn DL, Bustreo F, Raviglione MC.  Drug-resistant tuberculosis . Clin Infect Dis . 1997;;24( (suppl 1) ):S121-S130.

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