Strengthening the Delivery and Improving Outcomes of Drug-Resistant TB Treatment through Rational Medication Use Review

Introduction: A Rational Medication Use Review was conducted in health facilities in five high burden provinces (KwaZulu Natal, Western Cape, Eastern Cape, Gauteng and North West) that account for 77% of MDR-TB cases and 92% of XDR-TB in South Africa. Methodology: A purposive sampling of health facilities was done and stratified to represent different models of DR-TB service providers including centralized sites, decentralized sites, and satellite sites. Records for review were selected randomly among patients who initiated treatment between October 2011 and December 2012 and descriptive analysis conducted. Results: The review involved 139 patients (76.3% MDR-TB and 17.3% XDR-TB). 76.3% of them had a pretreatment DST and this was used for regimen selection. Renal function monitoring for dose adjustment was poor although baseline serum creatinine values were available on record for 69.1% of the patients. There was a high degree of missed doses with 66.7% of the patients having at least one missed dose. Co-morbid conditions were common with 66.2%, 13.0% and 5.8% of the patents with HIV, hypertension and seizure disorders respectively. Only 30.2% of the MDR-TB patents and 50% of the XDR-TB patients had been assessed for adverse drug reactions during the intensive phase although 125 episodes of ADRs were on record. Serum creatinine monitoring was not consistent (only 22.3% of patients had monthly values) although 16.1% of the patients had levels that would have required dose adjustments that were not done. Conclusion: There are many factors related to the patient, drug therapy, health care providers, and the health system that may adversely influence DR-TB treatment outcomes and patient safety. These can be detected early through regular rational medication use review and institutionalization of the process. This however requires a multidisciplinary approach with involvement of levels of the health system and various institutions involved TB in medication use.