重庆市肺科医院泛耐药结核病形成的临床原因分析  

Clinical analysis for the development of extensively drug-resistant tuberculosis in Chongqing,China

作　　者：张西雁[1] 金嘉琳[2] 范晓萍[2] 饶英[1] 钟敏[1] 张颖[2] 张文宏[2] 

机构地区：[1]重庆市肺科医院呼吸科,重庆400020 [2]复旦大学附属华山医院

出　　处：《中国感染与化疗杂志》2011年第3期174-177,共4页Chinese Journal of Infection and Chemotherapy

基　　金：国家重点基础研究发展计划项目(973计划)(2005CB523100);十一五重大专项项目(2008ZX10003-003)

摘　　要：目的泛耐药结核(XDR-TB)形成的原因有原发性耐药和获得性耐药两种,由于这两种来源形成耐药结核的防治措施不同,有必要对耐药形成的原因进行分类总结。方法对近10年来重庆市肺科医院收治的有完整病史记录的XDR-TB患者90例的临床资料进行分析。结果结果显示初始耐药47例,占52.2%,列第1位。耐药原因分析中不规律用药者30例,占总病例数的33.3%,其中患者依从性差,不遵医嘱用药最为常见,占66.7%(20/30),其余包括药物不良反应(肝功能损害、消化道反应、皮疹、视神经炎等)致无法耐受而间断不规则用药者,占23.3%(7/30)。初始方案力度不足8例(8/90),另有3例(3/90)患者在局部病灶(脊柱脓肿、腹腔脓肿、胸水)中分离到耐药菌。还有1例用药前是单耐药菌,治疗中诱导为耐多药菌。结论尽管有明确结核密切接触史者不多,初始耐药是造成耐药的第1位原因,需要加强宣教和隔离措施,防止耐药结核在社区的播散。不规律用药和初治方案用药不规范目前仍是引起耐药的主要原因,DOTS管理有待进一步规范。Objective Epidemics of drug-resistant tuberculosis may emerge by two mechanisms： acquired resistance and primary resistance.It is very important to distinguish between these two mechanisms of clinical failure,because control of the former depends on better management of patients,whereas controlling the latter requires enhanced efforts to find and treat infectious cases to interrupt transmission.MethodsWe collected 90 XDR-TB cases with complete history and analyzed the reasons of clinical failure.ResultsWe found that primary resistance was most frequent,accounted for 52.2% of XDR-TB,which was defined as resistant-culture result before treatment or no improvement after 3 month standard treatment.About 33.3% of XDR-TB was associated with irregular treatment,of which poor patient adherence accounted for 66.7%（20/30）.Interrupted therapy owing to adverse drug reaction including damaged liver function,gastrointestinal adverse reaction,rash,optic neuritis accounted for 23.3% of all XDR-TB cases.Inadequate initial treatment regimen was associated with 8.9% of the XDR-TB cases.XDR-TB was isolated from local lesions（intra-spinal abscess,intra-abdominal abscess and pleural effusion） in 3 cases.Another one case developed from mono-resistant before treatment to XDR later during therapy.ConclusionsAlthough definite history of close contact is not so prevalent（11.1%）,more than half of cases had primary resistance suggesting the transmission of drug-resistance,which will need more education and isolation to prevent further transmission within the community.Irregular treatment and inadequate initial treatment regimen remain an important factor leading to resistance.DOTS program should be strengthened.

关 键 词：泛耐药结核分枝杆菌 原发性耐药 获得性耐药 

分 类 号：R521[医药卫生—内科学] R378.911[医药卫生—临床医学]