Adverse events and treatment completion for latent tuberculosis in jail inmates and homeless persons

Background: Recently, a short-course treatment using 60 daily doses of rifampin and pyrazinamide was recommended for latent tuberculosis (TB) infection (LTBI). Study objectives: To determine the acceptability, tolerability, and completion of treatment. Design: Observational cohort study. Setting: Five county jails and TB outreach clinics for homeless populations in three cities. Patients: Study staff enrolled 1,211 patients (844 inmates and 367 homeless persons). Interventions: Sites used 60 daily doses of rifampin and pyrazinamide, an approved treatment regimen for LTBI. Measurements: Types and frequency of drug-related adverse events and outcomes of treatment. Results: Prior to treatment, 25 of 1, 178 patients (2.1%) had a serum aminotransferase measurement at least 2.5 times the upper limit of normal. Patients who reported excess alcohol use in the past 12 months were more likely than other patients to have an elevated pretreatment serum aminotransferase level (odds ratio, 2.1; 95% confidence interval, 1.1 to 6.1; p = 0.03). Treatment was stopped in 66 of 162 patients (13.4%) who had a drug-related adverse event. Among 715 patients who had serum aminotransferase measured during treatment, 43 patients (6.0%) had an elevation > 5 times the upper limits of normal, including one patient who died of liver failure attributed to treatment. In multivariate analyses, increasing age, an abnormal baseline aspartate aminotransferase level, and unemployment within the past 24 months were independent risk factors for hepatotoxicity. Completion rates were similar in jail inmates (47.5%) and homeless persons (43.6%). Conclusions: This study detected the first treatment-associated fatality with the rifampin and pyrazinamide regimen, prompting surveillance that detected unacceptable levels of hepatotoxicity and retraction of recommendations for its routine use. Completion rates for LTBI treatment using a short-course regimen exceeds historical rates using isoniazid. Efforts to identify an effective short-course treatment for LTBI should be given a high priority.