Real-World Outcomes of Ambulatory Drug-Susceptible Tuberculosis Management During the COVID-19 Pandemic in Romania

Background: Romania continues to experience one of the highest tuberculosis (TB) burdens in the European Union/European Economic Area. During the COVID-19 pandemic, reduced inpatient capacity accelerated the use of ambulatory care for patients with drug-susceptible tuberculosis (DS-TB). This study evaluated treatment outcomes, outcome ascertainment, hospitalization requirements, and factors associated with unfavorable outcomes among patients managed through ambulatory TB services. Methods: We conducted a retrospective observational cohort study of adults with pulmonary or extrapulmonary DS-TB managed through ambulatory tuberculosis dispensaries affiliated with the “Marius Nasta” Institute of Pneumophthisiology, Bucharest, Romania, between January 2020 and December 2022. Treatment outcomes were defined according to World Health Organization criteria. Factors associated with unfavorable outcome were assessed using Firth penalized-likelihood logistic regression. Hospitalization during treatment was analyzed as a secondary outcome. Results: The final cohort comprised 545 patients with DS-TB, with a mean age of 44.8 years and 56.1% being male. Overall, 281 of 545 patients achieved treatment success, corresponding to a WHO-defined treatment-success rate of 51.6%. Twenty-seven patients (5.0%) experienced an unfavorable outcome, while 237 (43.5%) were classified as not evaluated. Among the 308 patients for whom a determinate end-of-treatment outcome was available, 281 (91.2%) achieved treatment success; however, this conditional proportion does not represent the programmatic treatment-success rate for the entire cohort. Conclusions: Structured ambulatory DS-TB care was operationally feasible within this tertiary-care-linked dispensary network during the COVID-19 pandemic. However, the WHO-defined treatment-success rate for the entire cohort was 51.6%, largely reflecting the substantial proportion of patients without an evaluable final outcome. The high proportion of not-evaluated patients represents an important programmatic weakness and limits conclusions regarding the effectiveness of the ambulatory model. Improved outcome ascertainment and continuity of follow-up are essential components of decentralized TB care.