49例耐药脊柱结核的耐药表型及个体化治疗的回顾性分析  

Drug-resistant spectrums and retrospective study of individualize surgery and chemotherapy for patients with drug-re-sistant tuberculosis

作　　者：李建华[1] 陈非凡[2] 罗飞[1] 代飞[1] 侯天勇[1] 周强[1] 何清义[1] 许建中[1] 张泽华[1] 

机构地区：[1]第三军医大学西南医院骨科,重庆400038 [2]郑州大学第一附属医院,450052

出　　处：《中华骨科杂志》2016年第11期699-708,共10页Chinese Journal of Orthopaedics

基　　金：第三军医大学临床创新基金（SWH2011015）

摘　　要：目的回顾性分析耐药脊柱结核的耐药表型和个体化治疗耐药脊柱结核的疗效。方法筛选出2009年1月至2012年6月收治且符合纳入标准的耐药脊柱结核患者共49例。初治结核33例，复发复治结核16例。所有患者均根据病情和药敏检测结果制订个体化的手术方案和化疗方案，针对单耐药患者，适当加大异烟肼或利福平应用剂量并应用其他敏感药物替代治疗；对多耐药和耐多药患者根据药敏结果选择其他敏感药物并添加二线药物组成五联或六联化疗方案；对高度可疑广泛耐药结核患者，结合专科医院会诊意见，针对性选择最新药物或更改治疗方案（如MPaZ方案）等。49例患者获得规范完整的随访至少24个月。记录手术前后及随访获得的所有临床检查指标和影像学数据资料，并进行统计学分析。结果49例患者中单耐药结核（monoresistantce tuberculosis，MR-TB）14例，多耐药结核（polyresistance tubercu-losis，PR-TB）11例，耐多药结核（multi-drug resistant tuberculosis，MDR-TB）24例。耐药谱分布由高至低依次是异烟肼、利福平、链霉素、左氧氟沙星、帕斯烟肼（利福喷丁）、乙胺丁醇、丙硫异烟胺、卷曲霉素、对氨基水杨酸、阿米卡星。43例患者行开放性手术治疗；6例行CT引导下穿刺置管引流局部强化个体化化疗，置管时间39~60 d，平均（48±11）d。所有患者个体化化疗时间24~36个月，平均（29.5±2.5）个月。末次随访时疼痛视觉模拟评分（visual analogue scale，VAS）平均为（0.40±0.49）分，较术前（7.10±1.28）分明显降低，患者疼痛症状明显改善；红细胞沉降率平均为（11.31±4.60）mm/1 h和C反应蛋白（6.35±2.44）mg/L，均在正常范围。46例患者获得Ⅰ级骨愈合，3例获得Ⅱ级骨愈合。41例术前神经功能障碍患者均获得明显改善，根据ASIA分级，2例从B级恢复到D级，2例从B级到E级，9例从C级Objective To analyse the phenotypes of the drug-resistant tuberculosis, and investigate the outcomes of the individualize surgery and chemotherapy for these patients. Methods From January 2009 to June 2012, we retrospectively ana-lyzed 49 patients with drug-resistant tuberculosis spondylitis admitted in Southwest Hospital. 33 were initial cases and 16 were re-curring cases. All the 49 patients received individualized open operation or CT-guided percutaneous drainage and local chemother-apy depending on the characteristics of the focus. Individualized chemotherapy regimens were tailored for all patients according to the drug-resistant spectrum and all patients were followed up successfully at least 24 months. All the clinical data were collected＆amp;nbsp;and analyzed by statistical methods. Results Among the 49 patients, 14 were monoresistance tuberculosis, 11 were polyresis-tance tuberculosis, and 24 cases were multi-drug resistant tuberculosis. Frequence of the drug-restistance from high to low was Iso-niazid, Rifampicin, Streptomycin, Levofloxacin, Dipasic/Rifapentine, Ethambutol, Protionamide, Capreomycin, Paza-aminosalicy-late, and Amikacin. 43 patients received open operation and 6 patients received CT-guided percutaneous drainage and local che-motherapy. Time of the percutaneous drainage was （48±11） days （39-60 days）, and all patients received Individualized chemother-apy with an average of （29.5±2.5） months （24-36 months） postoperatively. At the last follow-up, all patients had remarkable pain remission, 44 patients with paraplegia got slight or remarkable recovery and 17 patients with kyphosis got significant correction. Conclusion The main drug-resistant spectrums are Isoniazid、Rifampicin、Streptomycin、Levofloxacin. The individualized sur-gery combined with individualized chemotherapy made according to the drug-resistance is a feasible treatment for the drug-resis-tant tuberculosis especially the multi-drug resistant tuberculosis.

关 键 词：结核 脊柱 广泛耐药结核 治疗结果 

分 类 号：R529.2[医药卫生—内科学]