Clinical consequences of non-compliance with directly observed therapy short course (DOTS): Story of a recurrent defaulter

In 1993, the World Health Organization (WHO) declared tuberculosis (TB) a global emergency, and subsequently introduced the directly observed therapy short course (DOTS) strategy, a technical and management package, based on the earlier work of the International Union Against Tuberculosis and Lung Disease (IUATLD) and international experience with DOTS, which strategy beyond a doubt has played a great role in the initial success of this program, especially in hospitalized patients under the initial intensive phase of 4-drug, anti-TB treatment with Isoniazid, Rifampicin, Pyrazinamide and Ethambutol. This results in rapid clinical well-being and early sputum conversion. This is indeed epidemiologically very important to break the chain of infection. Despite successful implementation of most of the elements of this strategy in several African countries and settings, TB case rates continue to escalate where the prevalence of HIV infection is high. There are also various other reasons which render the patients defaulter. Non-compliance is not only detrimental to the defaulters themselves as seen in this case study, but overall exposes the community to increased risk. Development of acquired resistance is more common in these patients, which makes their management very difficult. Therefore, it is important to anticipate those at risk of being defaulters and make them adhere to anti-TB treatment. It is very rare to trace and know what happened to a defaulter after he or she has dropped out, especially after migrating from one place to another, in the absence of any documentation. The following study is based on the story of a recurrent defaulter, a 64-year-old Saudi male who was admitted on 27 July 2011 to SBAH-City Rehabilitation Hospital & Medical Centre, Riyadh, Saudi Arabia.