Identifying multidrug resistance in previously treated tuberculosis patients: a mixed-methods study in Cambodia

SETTING: Previously treated tuberculosis (TB) patients are a priority for drug susceptibility testing (DST) to identify cases with multidrug-resistant TB (MDR-TB). A Cambodia study found that one third of smear-positive previously treated patients had DST results.OBJECTIVE: To quantify the gaps in the detection of MDR-TB in previously treated TB patients in Cambodia, and describe health workers' perspectives on barriers, facilitators and potential interventions.DESIGN: Analysis of Cambodia's 2004-2012 case notifications and semi-structured interviews with stakeholders.RESULTS: The proportion of previously treated notifications varied significantly across provinces in 2010-2012. If there had been no attrition along the path to detecting MDR-TB among smear-positive notified cases in 2012, an estimated 75 additional MDR-TB cases could have been identified, which would double the number actually detected. Most were lost due to misclassification of previously treated patients as 'new'. Barriers include patients' reluctance to disclose and staff difficulty in eliciting treatment history, partly attributed to the availability of streptomycin (SM) only in hospitals. Facilitators include collection of sputum for DST even if previously treated patients are not receiving SM, streamlining sputum transportation and prompt reporting of results.CONCLUSION: Improved monitoring, supportive staff supervision and training, patient education, and correct classification of previously treated cases are essential for improving the detection of MDR-TB.