安徽省非结核分枝杆菌临床分离率及人群分布和耐药性分析

doi:10.3969/j.issn.1000-6621.2020.07.014

摘要/Abstract

摘要：

目的分析安徽省非结核分枝杆菌(NTM)临床分离率和人群分布及耐药性情况,为NTM的防治提供科学依据。方法按照分层整群抽样方法从全省86个结核病门诊抽取42个调查点,连续纳入2015年9月15日至2016年8月31日的涂阳疑似肺结核患者3047例,对痰标本酸性罗氏培养阳性的2652株菌株行菌种鉴定[对硝基苯甲酸(PNB)培养和早期分泌蛋白(MPB64)胶体金法]和基因测序(16S rRNA和hsp65 DNA测序),再对其中的NTM临床分离株在不同人群中的分布特征和耐药性检测(微孔板法)进行研究和分析。结果 2652株培养阳性菌株经初步菌种鉴定获得122株NTM菌株,进一步经基因测序获得NTM临床分离株 107株[符合率为87.70%(107/122),分离率为4.03%(107/2652)]、结核分枝杆菌12株、诺卡菌1株、污染菌2株;其中107株NTM共计分离出6种优势菌种,以胞内分枝杆菌[65.42%(70/107)]和脓肿分枝杆菌[25.23% (27/107)]为主。NTM菌株在复治[9.26%(41/443)]、女性[6.32%(39/617)]、≥40岁[5.11%(100/1956)]、退休[8.82%(12/136)]和农民[4.38%(86/1965)]、初中及以下学历([4.43%(97/2189)]、家庭年收入<2万元[4.98%(75/1506)]人群中的分离率均明显高于初治[2.99%(66/2209)]、男性[3.34%(68/2035)]、<40岁[1.01%(7/696)]、工人[0.96%(1/104)]、高中及以上[2.16%(10/463)]、家庭年收入≥2万元[2.83%(27/955)]者[χ²值分别为37.434、10.854、36.387、17.021、18.995、8.748,P值分别为0.000、0.001、0.000、0.002、0.001、0.033]。104株(排除1株复苏失败的胞内分枝杆菌、1株草分枝杆菌和1株马赛分枝杆菌)菌株的药物敏感性试验结果显示,不同NTM对阿米卡星、利福布汀、克拉霉素和利福平的敏感度较高[分别为87.50%(91/104)、86.54%(90/104)、83.65%(87/104)、75.00%(78/104)],对亚胺培南/西司他丁、头孢西丁、米诺环素、多西环素等的耐药率较高[分别为100.00%(104/104)、95.19%(99/104)、94.23%(98/104)、93.27%(97/104)]。结论安徽省NTM的分离率较低,以复治、女性、40岁及以上、农民、低学历、低收入人群为主,且耐药率较高,应提升实验室鉴别和监测NTM的水平。

关键词: 分枝杆菌, 非典型性, 细菌学技术, 微生物敏感性试验, 抗药性, 细菌, 流行病学研究, 结果评价(卫生保健), 小地区分析

Abstract:

Objective To analyze the clinical isolation rate, population distribution and drug resistance of non-tuberculous mycobacteria (NTM) in Anhui to provide a scientific basis for the prevention and treatment of NTM. Methods Using the stratified cluster sampling method, 42 investigation points were collected from 86 tuberculosis clinics in Anhui, and 3047 cases of smear-positive suspected pulmonary tuberculosis patients from September 15, 2015 to August 31, 2016 were continuously included. The 2652 positive strains with acid L-G medium were identified for strains (p-nitrobenzoic acid (PNB) culture and early secreted protein (MPB64) colloidal gold method) and gene sequencing (16S rRNA and hsp65 DNA sequencing), and then the NTM was clinically isolated. The distribution characteristics and drug resistance detection (microplate method) of strains in different populations were studied and analyzed. Results The 2652 culture-positive strains obtained 122 NTM strains through preliminary strain identification; and by genetic sequencing, 107 NTM clinical isolates (the coincidence rate was 87.70% (107/122), and the isolation rate was 4.03% (107/2652)), 12 strains of Mycobacterium tuberculosis, 1 strain of Nocardia, and 2 strains of contaminated bacteria were further obtained. Among them, a total of 6 dominant bacterial species were isolated from the 107 strains of NTM, mainly of Mycobacterium intracellulare (65.42% (70/107)) and Mycobacterium abscessus (25.23% (27/107)). The rate of NTM isolation in retreatment (9.26% (41/443)), female (6.32% (39/617)), 40 years old and above (5.11% (100/1956)), retirement (8.82% (12/136)) and farmers (4.38% (86/1965)), junior high school and below (4.43% (97/2189)) and family annual income <20000 CNY (4.98% (75/1506)) were significantly higher than those in the initial treatment (2.99% (66/2209)), male (3.34% (68/2035)), under 40 years old (1.01% (7/696)), workers (0.96% (1/104)), high school and above (2.16% (10/463)), and family annual income ≥20000 CNY (2.83% (27/955)) (χ ² values were 37.434, 10.854, 36.387, 17.021,18.995 and 8.748, respectively; P values were 0.000, 0.001, 0.000, 0.002, 0.001 and 0.033, respectively). The drug susceptibility test results of 104 strains (excluding 1 strain of Mycobacterium intracellulare, 1 strain of Mycobacterium phlei, and 1 strain of Mycobacterium marseille which were failed to recover) showed that amikacin, rifabutin, clarithromycin and rifampicin were more sensitive (87.50% (91/104), 86.54% (90/104), 83.65% (87/104) and 75.00% (78/104), respectively), the resistance rates to imipenem/cilastatin sodium, cefoxitin, minocycline, doxycycline, etc. were higher (100.00% (104/104), 95.19% (99/104), 94.23% (98/104) and 93.27% (97/104), respectively). Conclusion The isolation rate of NTM in Anhui is lower, mainly in the retreatment, females, 40 years old and above, farmers, less educated and low income. The drug resistance rate is high, the laboratory identification and monitoring of NTM should be improved.

Key words: Mycobacteria, atypical, Bacteriological techniques, Microbial sensitivity tests, Drug resistance, bacterial, Epidemiologic studies, Outcome assessment (health care), Small-area analysis

包训迪, 江跃, 梁锁, 程红燕, 夏广秀, 王超, 叶倩, 王舒, 王庆. 安徽省非结核分枝杆菌临床分离率及人群分布和耐药性分析[J]. 中国防痨杂志, 2020, 42(7): 718-724. doi: 10.3969/j.issn.1000-6621.2020.07.014

BAO Xun-di, JIANG Yue, LIANG Suo, CHENG Hong-yan, XIA Guang-xiu, WANG Chao, YE Qian, WANG Shu, WANG Qing. Analysis of the clinical isolation rate, population distribution and drug resistance of non-tuberculous mycobacteria in Anhui[J]. Chinese Journal of Antituberculosis, 2020, 42(7): 718-724. doi: 10.3969/j.issn.1000-6621.2020.07.014

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检测方法	PNB		合计
检测方法	阳性	阴性	合计
MPB64抗原
阳性	3	3	6
阴性	112	4	116
合计	115	7	122

临床特征	培阳菌株数	结核分枝杆菌(株)	NTM(株)	NTM分离率(%)	χ²值	P值
患者类型					37.434	0.000
初治	2209	2141	66	2.99
复治	443	401	41	9.26
性别					10.854	0.001
男	2035	1965	68	3.34
女	617	577	39	6.32
年龄组(岁)					36.387	0.000
0~	76	76	0	0.00
20~	620	613	7	1.13
40~	758	734	23	3.03
60~	1198	1119	77	6.43
职业					17.021	0.002
农民	1965	1877	86	4.38
工人	104	103	1	0.96
退休	136	123	12	8.82
待岗	153	150	3	1.96
其他^a	294	289	5	1.70
文化程度					18.995	0.001
文盲	768	716	50	6.51
小学	668	642	25	3.74
初中	753	731	22	2.92
高中	298	291	7	2.35
大专及以上	165	162	3	1.82
家庭年收入(万元)					8.748	0.033
<2	1506	1430	75	4.98
2~	714	694	18	2.52
>5	241	232	9	3.73
拒绝透露	191	186	5	2.62
安徽省地区分布^b					0.360	0.835
北	1114	1067	46	4.13
中	1137	1088	47	4.13
南	401	387	14	3.49
合计	2649	2542	107	4.04	-	-

药品	胞内分枝杆菌(69株)	脓肿分枝杆菌(27株)	堪萨斯分枝杆菌(5株)	鸟分枝杆菌(3株)
利福平	9(13.04)	17(62.96)	0(0/5)	0(0/5)
克拉霉素	3(4.35)	14(51.85)	0(0/5)	0(0/5)
亚胺培南/西司他丁	69(100.00)	27(100.00)	5(5/5)	3(3/3)
阿奇霉素	63(91.30)	18(66.67)	2(2/5)	3(3/3)
利奈唑胺	61(88.41)	12(44.44)	1(1/5)	2(2/3)
阿米卡星	1(1.45)	12(44.44)	0(0/5)	0(0/1)
乙胺丁醇	1(1.45)	27(100.00)	5(5/5)	3(3/3)
利福布丁	3(4.35)	11(40.74)	0(0/5)	0(0/1)
头孢西丁	64(92.75)	20(74.07)	5(5/5)	3(3/3)
妥布霉素	13(18.84)	20(74.07)	5(5/5)	0(0/1)
莫西沙星	13(18.84)	13(48.15)	0(0/5)	1(1/3)
加替沙星	54(78.26)	21(77.78)	1(1/5)	2(2/3)
多西环素	68(98.55)	23(85.19)	4(4/5)	2(2/3)
米诺环素	69(100.00)	22(81.48)	4(4/5)	3(3/3)
磺胺甲唑	66(95.65)	23(85.19)	2(2/5)	3(3/3)