Community-based management versus traditional hospitalization in treatment of drug-resistant tuberculosis:a systematic review and meta-analysis

Background:Multidrug drug resistant Tuberculosis(MDR-TB)and extensively drug resistant Tuberculosis(XDR-TB)have emerged as significant public health threats worldwide.This systematic review and meta-analysis aimed to investigate the effects of community-based treatment to traditional hospitalization in improving treatment success rates among MDR-TB and XDR-TB patients in the 27 MDR-TB High burden countries(HBC).Methods:We searched PubMed,Cochrane,Lancet,Web of Science,International Journal of Tuberculosis and Lung Disease,and Centre for Reviews and Dissemination(CRD)for studies on community-based treatment and traditional hospitalization and MDR-TB and XDR-TB from the 27 MDR-TB HBC.Data on treatment success and failure rates were extracted from retrospective and prospective cohort studies,and a case control study.Sensitivity analysis,subgroup analyses,and meta-regression analysis were used to explore bias and potential sources of heterogeneity.Results:The final sample included 16 studies involving 3344 patients from nine countries;Bangladesh,China,Ethiopia,Kenya,India,South Africa,Philippines,Russia,and Uzbekistan.Based on a random-effects model,we observed a higher treatment success rate in community-based treatment(Point estimate=0.68,95%CI:0.59 to 0.76,p<0.01)compared to traditional hospitalization(Point estimate=0.57,95%CI:0.44 to 0.69,p<0.01).A lower treatment failure rate was observed in community-based treatment 7%(Point estimate=0.07,95%CI:0.03 to 0.10;p<0.01)compared to traditional hospitalization(Point estimate=0.188,95%CI:0.10 to 0.28;p<0.01).In the subgroup analysis,studies without HIV co-infected patients,directly observed therapy short course-plus(DOTS-Plus)implemented throughout therapy,treatment duration>18 months,and regimen with drugs>5 reported higher treatment success rate.In the meta-regression model,age of patients,adverse events,treatment duration,and lost to follow up explains some of the heterogeneity of treatment effects between studies.Conclusion:Community-based management improved treatment outcomes.A mix of interventions with DOTSPlus throughout therapy and treatment duration>18 months as well as strategies in place for lost to follow up and adverse events should be considered in MDR-TB and XDR-TB interventions,as they influenced positively,treatment success.