A case study of a patient with

multidrug-resistant tuberculosis
Ruth Cornish
ABSTRACT In this case study, a nurse presents her reflections on the challenges of supporting a patient through
his treatment journey for multidrug-resistant tuberculosis. The patient has significant comorbidities and social issues,
such as diabetes and homelessness. There was also a language barrier. All these aspects made the management of
his treatment challenging. The medication side effects and his lifestyle were also a barrier to full engagement. The
same multidisciplinary team was involved with the patient and, despite the obstacles, he seemed willing to engage
with treatment and the team.
Key words: Multidrug-resistant tuberculosis ■ Under-served population
■ Pulmonary TB ■ Language barrier ■ Multidisciplinary team ■ Comorbidities
Ruth Cornish is a community nurse working in South West England, ruthcornish@nhs.net
Accepted for publication: July 2018
To protect the patient’s identity, the patient’s name has been changed and no identifying information has been used.
Case study Fred was a well-built, non-UK born individual, who was admitted to hospital with a chest infection,
following a month of feeling unwell. He had several issues that could impact on his treatment outcome:
homelessness, alcoholism, he had poorly controlled diabetes and there was also a language barrier, all of which are
reflected on in the discussion of his case. Fred’s English was limited to about 100 words: he was unable to recognise

days of the week or to put together a sentence such T

uberculosis with concern In who this misuse poverty, context, about (TB) drugs TB this and is includes in a or there
disease the alcohol, under-served is homeless that currently those is often people, with population. a associated
growing
mental people
as ‘I would like tea with milk’.
On admission, Fred’s chest X-ray revealed cavities and there was a high suspicion of TB. He also had the following
comorbidities: ischaemic heart disease and kidney damage, probably secondary to his poorly controlled diabetes.
Fred had been living in a tent for a couple of months, and was known to be a heavy drinker. illness and those who
have been in prison. Treatment outcomes
In cases of pulmonary TB contact tracing is an important among this population tend to be poor and they are more
likely
part of the nurse’s role but, despite repeated efforts and working to have resistant TB (Public Health England (PHE),
2017a).
with the homeless services, we were only able to trace two of In 2016, people in the under-served population made
up
Fred’s contacts. They were both asymptomatic and Quantiferon 11.1% of all TB cases (PHE, 2017b). In total, there
were 68
negative (Quantiferon-TB Gold is a blood test used to detect cases of multidrug-resistant TB (MDR-TB) in England
in
latent tuberculosis). Fred repeatedly said that he did not know 2017, which was 1.7% of all TB cases (PHE, 2017b).
This is a
the real names of the people he shared a tent with. growing concern because MDR-TB is notoriously difficult to
Sputum samples were sent for TB culture and sensitivities, and treat. In 2014, only 49% of people notified as having
MDR-TB
found to be acid-fast bacillus (AFB) negative. Whole-genome managed to complete 24 months of treatment (PHE,
2017a).
sequencing (WGS) and polymerase chain reaction (PCR) The current recommended treatment course is 24 months,
but
testing, which is a molecular technique that enables analysis there is growing interest in the Bangladesh regimen,
which is
of short pieces of DNA, were not readily available at the time. a 9-month course (Box 1).
WGS and PCR help inform the prescribing physician which Poor treatment compliance can be explained partly by
people
antibiotics the TB is sensitive to. being unable to manage the side-effects of the medication and
Fred was started on anti-TB treatment of Rifater (which the longer the course of treatment the harder it is for
compliance
contains rifampicin, isoniazid and pyrazinamide) and to be maintained. This can result in treatment being stopped
moxifloxacin, which was used instead of ethambutol due early, as intermittent therapy can cause further drug
resistance.
to concerns about Fred’s eyesight (one of the side effects of This article is a nurse’s reflections on the challenges of
ethambutol is ocular damage). TB is a slow-growing bacteria supporting a person throughout their treatment for
MDR-TB.
and it can take up to 8 weeks to get the culture results which, in Fred’s case, took 7 weeks, confirming that he had
MDR-TB. MDR-TB, is resistant to the most effective of TB antibiotics, rifampicin and isoniazid and, as Fred had
already been on moxifloxacin for 7 weeks, it was not possible to start him on the Bangladesh regimen. The 9-month
antibiotic course is perceived as being easier for people to manage compared with
806 British Journal of Nursing, 2018, Vol 27, No 14
Downloaded from magonlinelibrary.com by 130.209.006.061 on August 2, 2018.

CLINICAL FOCUS
the standard 24-month course, which can feel as if there is no end to it. MDR-TB drug regimens are difficult for
many people
Box 1. The Bangladesh regimen
to tolerate as the side effects can impinge on their quality of life. Globally, treatment success rates for MDR TB are
54% (World Health Organization (WHO), 2017).
Initial management of MDR-TB focuses on reducing the
The Bangledesh regimen is a 9-month treatment course, as opposed to the standard length of treatment for multidrug- resistant
tuberculosis (MDR-TB), which ranges from 18 to 24 months, thereby helping to make it more tolerable to people. The initial
treatment results look positive. risk
of transmission. National Institute for Health and Care
Exclusion criteria include: Excellence
(NICE) guidelines (NICE, 2016) recommend that a patient is barrier nursed in a
negative pressure room until they have had three culture-negative sputa. The rationale for this is that the physicians
can be certain that the risk of transmission
Downloaded from magonlinelibrary.com by 130.209.006.061 on August 2, 2018.
■ Confirmed resistance to any of the drugs in the shorter regimen
■ Exposure to a second-line drug, such as moxifloxacin, for greater than a month
to the medication used in the shorter regime is zero. Fred was isolated in a hospital room for three and a
■ Intolerance

■ Pregnancy half months.

■ Extrapulmonary disease Research has shown that enforced isolation can be extremely detrimental to a person’s

wellbeing and can result in them

Source: World Health Organization, 2016
experiencing episodes of paranoid hallucination, panic attacks,
he had long-term support he was assigned a tenancy support reduced concentration and memory loss (Grassian,
2006). The
worker. Fred was given a bus pass, which helped him to attend TB team made efforts to ensure that Fred’s room was
as homely
his numerous hospital appointments. In my view, the continuous as possible so, for example, he was able to decorate
the room
support to meet his welfare needs helped to motivate Fred with his national flag, he had an exercise bike and a
computer.
to engage with the TB nurses, and therefore to maintain his For Christmas, at his request, the TB team gave him a
Christmas
treatment. Lutge et al (2015), Thomas et al (2016) and Potter tree for his room. He also had a wall diary that showed
him
et al (2016) found that material incentives, certainly at the start the schedule for his tests and also when members of
the team
of treatment, help vulnerable people to maintain compliance, would be visiting. He was allowed to go out into the
hospital
although they stated that more research is needed to establish grounds for a cigarette, as long as he wore a mask
when he
if it helps for the duration of treatment. walked through the hospital.
Fred was a heavy drinker and resolutely refused to discuss his Thomas et al (2016) found that people with TB often
habit, or to receive help for it. He would describe beer as water experience depression, which can be exacerbated by
the
and would joke about how he put vodka in bottles of coke to medications, which can induce paranoia, hallucinations
and
make it look like he was not drinking. Alcohol has been found lead to deeper depression (Vega et al, 2004). At
times, Fred
in several studies to reduce the chances of a person completing was convinced that we were poisoning him and
making him
treatment (Duraisamy et al, 2014; Thomas et al, 2016). Excessive ill. It was impossible to convince him of anything
else, so the
alcohol reduces the body’s immune system’s ability to combat TB nurses would often simply listen to him talking
about
infection (Rehm et al, 2009) and impacts on which drugs can his feelings. Fred was taking 40 tablets a day, so he
was not
be prescribed safely. Fred’s cycloserine was stopped, as it could willing to consider taking further medication to
control the
have led to him having fits and experiencing psychosis. side effects. He was on 100 mg of pyridoxine to help reduce
When he was drunk, his behaviour was erratic and the neurotoxicity of the medication. His peripheral neuropathy
intimidating. A risk assessment was carried out before discharge was difficult to assess as he had reduced sensation
in his feet,
and it was agreed that lone visiting was not safe. Most days due to his diabetes.
Fred meet with the TB nurses at a health centre, and on rare occasions two of us would do home visits: this was
usually if Social support
he had not attended for a while. On our last home visit, there After 3 months of treatment Fred’s sputa came back
culture
were three other men with Fred, who were all heavily under negative, but it took a further 3 months to establish how
he could
the influence of alcohol. be accommodated in the community. NICE (2016) guidelines indicate that homeless TB
patients should have assistance with
Diabetes management finding and funding of accommodation (PHE, 2017a) to aid
Research indicates that poor diabetic control makes it harder compliance while on treatment. Fred was not eligible
for council
to control tuberculosis. Diabetics are often slower to become accommodation, but he was able to claim housing
benefit, which
sputum culture-negative than non-diabetics. Diabetes results did not cover the full cost of self-contained
accommodation.
in poor treatment outcomes and an increased chance of This meant there were several complex multidisciplinary
reactivation. Baker et al (2011) and Dooley and Chaisson (2009) team (MDT) meetings to discuss his eligibility for
help and
therefore recommended increased monitoring of diabetes in determine which organisation(s) would fund his housing
needs.
such patients and improving their glucose control. Eventually, the local clinical commissioning group and Public
On initial admission, Fred’s HbA1c was 112 mmol/mol and, Health England made up the differential between the
rent and
during treatment, it was running at 70 mmol/mol (normal benefits for a year.
HbA1C range is 36-42 mmol/mol). While in hospital, he was The TB nursing team helped Fred to apply for
benefits,
put on an insulin regimen of Levemir and NovoRapid with furniture and to manage his bills. In an attempt to ensure
that
meals; however, Fred administered his insulin on ad hoc basis
British Journal of Nursing, 2018, Vol 27, No 14 807

it KEY POINTS
was essential that the doctors and nurses worked together to provide consistent messages. All letters pertaining to his
■ It can be difficult to engage with patients who are homeless, and the
treatment, and potential consequences of non-compliance were input of the multidisciplinary team (MDT) is vital to
ensure continuity of
translated into his mother tongue. care, which is especially important in the case of patients with multidrug- resistant
tuberculosis
TB treatment
■ Itis important to ensure consistency of the information provided to the patient by all members of the MDT
■ Supporting the patient with obtaining benefits and accommodation acted as a major incentive to his engagement
with the healthcare team and adherence to treatment
■ Due to the patient’s erratic lifestyle, directly observed therapy and then video-observed therapy were offered to
encourage compliance with the treatment regimen
Throughout his treatment Fred attended all his TB hospital appointments and engaged with the MDT meetings. The
MDT agenda intended to ensure that all the professionals were giving Fred the same messages and make sure that he
was fully aware of the importance of maintaining compliance and the potential consequences if his TB became
infectious.
Each week, Fred had two or three hospital appointments, on top of his daily appointments with the TB nurses for
directly observed therapy (DOT), which is offered to everyone who is on an MDR-TB regimen, and to monitor and
manage the and would only give himself a dose that he felt was right. Several
side-effects of the medication. DOT is recognised by the WHO attempts were made to get him to engage with his
primary
(2011) and NICE (2017) as being a good tool to support healthcare team to improve his diabetic control; this
included
compliance, and to monitor the number of doses missed. This the TB nurses and an interpreter taking him to an
appointment.
support is offered to everyone who is on an MDR-TB regimen. He was very resistant to any help with his diabetes
management,
His other appointments were to manage his comorbidities, and during his last stay in hospital he became angry with
anyone
obtain induced sputum for testing, hearing tests and monthly who attempted to discuss it with him.
electrocardiograms. I think that he found that the sheer number Fred’s peripheral neuropathy caused him a lot of
discomfort;
of appointments impinged on his ability to lead a normal life. and he developed a small ulcer on the sole of his foot,
1 cm
Fred was used to leading an unstructured lifestyle. deep. He refused to go to the community services to have his
The side-effects of the medication for MDR-TB are foot dressed and would often not attend hospital appointments
varied and difficult to manage (Furin et al, 2001), for example, to manage his foot. This meant that the TB nurses
would, on
clofazimine can make the patient’s skin turn a burnt orange occasion, dress his feet and facilitate him attending the
hospital
colour, affecting their self-image. Amikacin can cause ringing podiatry service. Fred would occasionally miss his
podiatry
in the ears and permanent hearing damage. Most people on appointments and this would result in him being
discharged
an MDR-TB regimen describe experiencing intense nausea from the service, and each time this happened he had to
be
and dizziness, which make leading a normal life difficult. Fred re-referred. Fortunately, his foot ulcer eventually
healed.
would tell us that, after taking the mediation, he had to go home and lie down for several hours. His sleeping
patterns Language barrier
were disturbed and his appetite was reduced. Fred would often Fred’s reluctance to engage with services could have
been driven
complain that the medications were poisoning him, and that by a number of factors, ranging from personality to his
alcohol
he felt better on the days that he did not take it. use and the language barrier. In Fred’s case, it was not always
During treatment, Fred was admitted on two occasions to possible for each practitioner to have an interpreter present
manage medication side-effects. Various strategies were tried, for all of his appointments and, if a telephone
interpreter was
such as changing the time of his medication to evening, to used, he would get frustrated and start to disengage from
the
enable him to sleep through the worst of the side effects. This service. Research has shown that a language barrier
can affect
meant the TB nurses were unable to provide DOT. Fred was a person’s ability to understand and participate in their
health
offered a video-observed therapy (VOT) support system, which care, which can result in poor outcomes (Gerrish et
al, 2004;
involves the patient sending in daily videos of themselves taking Karliner et al, 2012). The language barrier made
interaction
the medication. They can give feedback about themselves, and with Fred at times challenging and probably
frustrating for him
get access to help, if necessary. Fred was totally uninterested too, as it was difficult to get across nuances and to
develop a
in the idea. The changing of his medication time was done rapport through a third person. An interpreter was present
for
reluctantly, following a two-week period during which he most of his hospital appointments and at least once a week
for
refused to take any medication, citing the side-effects as his his meetings with the TB nurses.
reason. Unfortunately, this quickly resulted in a further reduction We were fortunate to work mainly with one
interpreter,
in Fred’s compliance. He was taking half his doses which, over who was willing to help with applications for
benefits and
a protracted period, could have resulted in extensively drug- with managing Fred’s affairs. I think he really valued
the service
resistant TB (Lange et al, 2014). she provided. The language barrier did have an impact on
Fred was admitted for the last phase of his treatment because his understanding of his health issues, though, and
possibly
he was not able to maintain it at home. The ward struggled with contributed to Fred’s feelings that the medicines
were poisoning
this, as he had a tendency to leave and return drunk. Following him. He thought we were experimenting on him.
This meant
a discussion with the British Thoracic Society, it was felt that
808 British Journal of Nursing, 2018, Vol 27, No 14
Downloaded from magonlinelibrary.com by 130.209.006.061 on August 2, 2018.

CLINICAL FOCUS
the safest option was to stop treatment 15 months into the course. However, Fred self-discharged two weeks before
that date. His last scan showed that his lung cavities were reduced but still there. He was smear and culture negative,
and was adamant that he was not going to take any more treatment. To date Fred reports that he is well and he will
be reviewed and have induced sputum every 3 months.
Fred attended for the first few appointments after his treatment had stopped, however he has not recently attended.
His next appointment is in August, and the TB nursing team will actively encourage him to attend.
Reflection In England, only 49% of people notified as having MDR- TB in 2014 completed their treatment
course and 20% were lost to follow up (PHE, 2015) One of the reasons for this is thought to be down to the side
effects and the length of the antibiotic course (24 months). Due to the increasing availability of PCR and WGS it
may be possible to put more people on the Bangladesh regime: this is because the sensitivities result will come back
more quickly than the sputum results, so the prescribing clinician will know which antibiotics to prescribe. In Fred’s
case, he had been on moxifloxacin for 7 weeks before the sensitivities were available and so could not be started on
the Bangladesh regimen.
Fred’s compliance for the first 9 months of treatment was good. My impression was that he genuinely wanted to
complete the course, but the medication side effects and his lifestyle choices made it impossible. He seemed willing
to engage with the TB team, and I think this was because we worked with him to facilitate him getting
accommodation, benefits and furniture. I think that, without these incentives, he would have less motivation for
engagement with the team and this would have reduced his treatment.
This case study illustrates how important it is for homeless patients with TB to have their welfare needs supported
and to have a consistent therapeutic team working with them to provide support. BJN
Acknowledgement: thanks to all members of the multidisciplinary team involved in the care of this patient
Baker MA, Harris AD, Jeon CY et al. The impact of diabetes in tuberculosis
treatment outcomes: a systematic review. BMC Med. 2011; 9: 81. https:// doi.org/10.1186/1741-7015-9-81
Downloaded from magonlinelibrary.com by 130.209.006.061 on August 2, 2018. Dooley K, Chaisson R. Tuberculosis and diabetes mellitus: convergence
of two epidemics. Lancet Infect Dis. 2009; 9(12): 737–46. https://doi. org/10.1016/S1473-3099(09)70282-8 Duraisamy K, Mrithyunjayan S, Ghosh S
et al. Does alcohol consumption during multidrug-resistant tuberculosis treatment affect outcome. A population-based study in Kerala, India. Ann Am
Thorac Soc. 2014; 11(5): 712–8. https://doi.org/10.1513/AnnalsATS.201312-447OC Furin JJ, Mitnik CD, Shin SS et al. Occurrence of serious adverse
effects
in patients receiving community based therapy for multi-drug resistant tuberculosis. Int J Tuberc Lung Dis. 2001; 5(970): 649–655 Gerrish K, Chau R,
Sobowale AA, Birks E. Bridging the language barrier: the
use of interpreter in primary care nursing. Health Soc Care Community. 2004; 12(5): 407–13. https://doi.org/10.1111/j.1365-2524.2004.00510.x
Grassian S. Psychiatric effects of solitary confinement. Journal of Law And
Policy. 2006; 22: 324–383. https://tinyurl.com/ybcntrrz (accessed 16 July 2018)) Karliner LS, Auerbach A, Nápoles A, Schillinger D, Nickleach D,
Pérez-
Stable EJ. Language barriers and understanding of hospital discharge instructions, Med Care. 2012; 50(4): https://doi.org/10.1097/
MLR.0b013e318249c949 Lange C, Abubakar I, Alffenaar W-J C et al. Management of patients with
multidrug-resistant extensively drug-resistant tuberculosis. A TBNet consensus statement. Eur Respir J. 2014; 44(1): 23-63. https://doi.
org/10.1183/09031936.00188313 Lutge EE, Wiysonge CS, Knight SE, Sinclair D, Volmink J. Incentives and
enablers to improve adherence in tuberculosis. Cochrane Database Syst Rev. 2015;(9):CD007952. https://doi.org/10.1002/14651858.CD007952. pub3
National Institute for Health and Care Excellence. Tuberculosis. NICE guideline NG33. 2016. https://tinyurl.com/yded34bp (accessed 16 July 2018)
National Institute for Health and Care Excellence. Quality statement 5:
Directly observed therapy. In NICE. Tuberculosis. Quality standard QS141. 2017. https://tinyurl.com/ybas2hno (accessed 16 July 2018) Public Health
England. Tuberculosis in England. 2016 report (presenting data
to end of 2015). 2015. https://tinyurl.com/ycrlzfca (accessed 16 July 2018) Public Health England. Tackling tuberculosis in under-served populations:
a resource for TB control boards and their partners. 2017a. https://tinyurl. com/y7s8q8fn (accessed 16 July 2018) Public Health England. Tuberculosis
in England. 2017 report (presenting data to
end of 2016) 2017b. https://tinyurl.com/y82forfo (accessed 16 July 2018) Potter JL, Inamadar L, Okereke E, Collinson S, Dukes R, Mandelbaum R.
Support of vulnerable patients throughout TB treatment in the UK. J Public Health (Oxf). 2016; 38(2): 391–395. https://doi.org/10.1093/
pubmed/fdv052 Rehm J, Samokhvalov AV, Neuman MG et al. The association between alcohol use, alcohol use disorders and tuberculosis (TB). A
systematic review. BMC Public Health. 2009; 9:450. https://doi.org/10.1186/1471-2458-9-450) Vega P, Sweetland A, Acha J et al. Psychiatric issues
in the management of
patients with multidrug-resistant tuberculosis. Int J Tuberc Lung Dis. 2004; 8(6): 749–59. https://tinyurl.com/y9x96svw (accessed 16 July 2018)
Thomas BE, Shanmugam P, Malaisamy M et al. Pyscho-socio-economic
issues challenging multidrug resistant tuberculosis patients: A systematic review. PLoS One. 2016; 11(1): e0147397. http://doi.org/10.1371/journal.
pone.0147397thomas World Health Organization. Guidelines for the programmatic management
of drug resistant tuberculosis. 2011 update. 2011. https://tinyurl.com/ y7xg6h6v (accessed 16 July 2018) World Health Organization. The shorter
MDR-TB regimen. 2016. https://
tinyurl.com/ycmln2w3 (accessed 18 July 2018) World Health Organization. Tuberculosis. Global Tuberculosis report 2017.
2017. https://tinyurl.com/yajlde6x (accessed 19 July 2018)2015

CPD reflective questions

■ In your practice, what strategies do you employ to support people to manage complex and/or unpleasant treatment
regimens?
■ In your team, can you think of ways to support people, whose first language is not English, with their health needs?
■ How accessible is your service to people who have chaotic lifestyles, such as homelessness or drug and alcohol
issues?
British Journal of Nursing, 2018, Vol 27, No 14 809