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中国防痨杂志 ›› 2022, Vol. 44 ›› Issue (10): 1028-1036.doi: 10.19982/j.issn.1000-6621.20220195

• 论著 • 上一篇    下一篇

耐多药肺结核治愈患者复发的影响因素分析

杨小钰1, 邱磊2, 张顺先1, 张少言1, 周伟1, 吴显伟1, 吴定中1, 张惠勇2, 肖和平3, 鹿振辉1()   

  1. 1上海中医药大学附属龙华医院呼吸疾病研究所,上海 200032
    2上海中医药大学附属龙华医院肺病科,上海 200032
    3同济大学附属上海市肺科医院结核科,上海 200433
  • 收稿日期:2022-05-23 出版日期:2022-10-10 发布日期:2022-09-30
  • 通信作者: 鹿振辉 E-mail:Dr_luzh@shutcm.edu.cn
  • 基金资助:
    “十三五”国家科技重大专项(2018ZX10725-509);国家中医药多学科交叉创新团队(ZYYCXTD-D-202208);上海市2021年度“科技创新行动计划”医学创新研究专项(21Y11922500);上海中医药大学附属龙华医院人才基金(LH001.007);上海市促进市级医院临床技能与临床创新能力三年行动计划(SHDC2022CRS039)

Analysis of influencing factors of recurrence in cured patients with multidrug-resistant pulmonary tuberculosis

Yang Xiaoyu1, Qiu Lei2, Zhang Shunxian1, Zhang Shaoyan1, Zhou Wei1, Wu Xianwei1, Wu Dingzhong1, Zhang Huiyong2, Xiao Heping3, Lu Zhenhui1()   

  1. 1Respiratory Diseases Institute, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
    2Pulmonary Disease Section, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
    33Department of Tuberculosis, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai 200433, China
  • Received:2022-05-23 Online:2022-10-10 Published:2022-09-30
  • Contact: Lu Zhenhui E-mail:Dr_luzh@shutcm.edu.cn
  • Supported by:
    The 13th Five-Year National Science and Technology Major Project(2018ZX10725-509);National Traditional Chinese Medicine Multidisciplinary Interdisciplinary Innovation Team(ZYYCXTD-D-202208);Medical Innovation Research Special Project of the Shanghai 2021 “Science and Technology Innovation Action Plan”(21Y11922500);Talent Fund of Longhua Hospital, Shanghai University of Traditional Chinese Medicine(LH001.007);Three-year Action Plan for Promoting Clinical Skills and Innovation Ability of Municipal Hospitals of Shanghai(SHDC2022CRS039)

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摘要：

目的:分析耐多药肺结核(multidrug-resistant pulmonary tuberculosis,MDR-PTB)患者治愈后复发的危险因素。方法:采用回顾性研究方法,搜集2013年1月至2017年12月期间来自全国15个省份的18家医院的经长程(18~24个月)化疗方案(6Am-Lfx-P-Z-Pto/18Lfx-P-Z-Pto;Am:阿米卡星,Lfx:左氧氟沙星,P:对氨基水杨酸钠,Z:吡嗪酰胺,Pto:丙硫异烟胺)治愈并随访3年的600例MDR-PTB患者作为研究对象。收集研究对象的基本信息、临床信息和实验室检测结果,包括性别、年龄、体质量指数、慢性病病史、结核病病史(接受本长疗程化疗方案前)、治疗用药情况,以及痰涂片、痰培养、药物敏感性试验、胸部CT扫描、血常规、血红细胞沉降率、尿常规、肝肾功能等资料。分析MDR-PTB患者治愈后复发的危险因素,并通过受试者工作特征曲线评价复发危险因素对MDR-PTB复发的预测价值。结果:600例研究对象,治愈后随访3年,发现有40例复发,复发率为6.7%(40/600;95%CI:4.9%~9.1%)。多因素logistic回归分析结果显示:血红细胞沉降率升高[OR(95%CI)=2.705(1.136~6.444)]、总胆红素水平升高[OR(95%CI)=5.329(1.408~20.170)]、尿蛋白水平升高[OR(95%CI)=5.642(1.650~19.292)]、尿糖水平升高[OR(95%CI)=5.333(1.357~20.954)]、使用环丝氨酸[OR(95%CI)=11.771(3.920~35.347)]、肺结核初次诊断到MDR-PTB初次诊断时间≥1年[OR(95%CI)=8.730(2.710~28.119)]、有空洞[OR(95%CI)=32.806(6.096~176.557)]是MDR-PTB复发的独立危险因素。受试者工作特征曲线分析显示,以logistic回归分析总体模型为检验变量时,曲线下面积最大(0.932)。结论:应重点关注血红细胞沉降率、总胆红素水平、尿蛋白水平、尿糖水平高于正常值范围,以及肺结核初次诊断到MDR-PTB初次诊断时间≥1年和合并空洞MDR-PTB患者的治疗和随访,并合理规范使用环丝氨酸。

关键词: 结核,肺, 抗药性,多药, 复发, 危险因素

Abstract:

Objective:To analyze the risk factors of recurrence in cured patients with multidrug-resistant pulmonary tuberculosis (MDR-PTB). Methods:A retrospective study was conducted in 600 MDR-PTB patients who were cured by long-term (18-24 months) chemotherapy (6Am-Lfx-P-Z-Pto/18Lfx-P-Z-Pto; Am: amikacin, Lfx: levofloxacin, P: sodium p-aminosalicylate, Z: pyrazinamide, Pto: prothionamide) and followed up for 3 years from 18 hospitals in 15 provinces between January 2013 and December 2017. The basic information, clinical information and laboratory test results of the subjects were collected, including gender, age, body mass index, history of chronic disease, history of tuberculosis (before receiving this long-term chemotherapy regimen), treatment and medication status, as well as sputum smear, sputum culture, drug sensitivity test, chest CT scan, routine blood test, erythrocyte sedimentation rate, routine urine test, liver and kidney function, etc. The risk factors of recurrence in cured MDR-PTB patients were analyzed, and the predictive value of recurrence risk factors for MDR-PTB recurrence was evaluated by receiver operating characteristic curve. Results:The 3-year recurrence rate of the 600 MDR-PTB patients was 6.7% (40/600; 95%CI: 4.9%-9.1%). Logistic multivariate regression analysis showed that elevated erythrocyte sedimentation rate (OR (95%CI)=2.705 (1.136-6.444)), elevated total bilirubin (OR (95%CI)=5.329 (1.408-20.170)), elevated urinary protein (OR (95%CI)=5.642 (1.650-19.292)), elevated urine glucose (OR (95%CI)=5.333 (1.357-20.954)), usage of cycloserine (OR (95%CI)=11.771 (3.920-35.347)), the time from the initial diagnosis of pulmonary tuberculosis to the initial diagnosis of MDR-PTB ≥1 year (OR (95%CI)=8.730 (2.710-28.119)), and cavity (OR (95%CI)=32.806 (6.096-176.557)) were independent risk factors for MDR-PTB recurrence. The receiver operating characteristic curve analysis showed that when the logistic regression analysis overall model was used as the test variable, the area under the curve was the largest (0.932). Conclusion:Attention should be paid to the erythrocyte sedimentation rate, total bilirubin level, urine protein level and urine sugar level when they higher than the normal levels, as well as the treatment and follow up of MDR-PTB patients with the initial diagnosis of PTB to the initial diagnosis of MDR-PTB ≥1 year, and MDR-PTB patients with cavities, furthermore, the use of cycloserine should be reasonable and standardized.

Key words: Tuberculosis,pulmonary, Drug resistance,multiple, Recurrence, Risk factors

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