249例老年肺结核患者耐药状况及产生耐多药的危险因素分析

doi:10.3969/j.issn.1000-6621.2021.06.020

摘要/Abstract

摘要：

收集2020年1月1日至12月31日于沈阳市第十人民医院住院诊治的痰培养阳性且菌种鉴定为结核分枝杆菌的249例老年肺结核患者的药物敏感性试验结果及临床资料,统计分析其耐药状况,采用卡方检验和多因素logistic回归模型分析其发生耐多药的危险因素。结果显示,249例老年肺结核患者的总耐药率、初治耐药率、复治耐药率分别为32.53%(81/249)、24.24%(40/165)、48.81%(41/84),复治耐药率明显高于初治耐药率,差异有统计学意义(χ²=15.307,P=0.000)。总耐多药率、初治耐多药率、复治耐多药率分别为12.85%(32/249)、7.27%(12/165)、23.81%(20/84),复治耐多药率明显高于初治耐多药率,差异有统计学意义(χ²=13.591,P=0.000)。无广泛耐药患者。经多因素logistic回归分析显示,复治(OR=4.201,95%CI=1.467~12.033)、有肺结核空洞(OR=2.406,95%CI=1.019~5.681)是老年肺结核患者发生耐多药的独立危险因素。可见,老年肺结核患者耐药率较高,应积极开展耐药筛查。复治、有肺结核空洞是老年肺结核患者发生耐多药的独立危险因素。

关键词: 结核,肺, 老年人, 结核,抗多种药物性, 因素分析,统计学

Abstract:

Results of drug sensitivity test and clinical data of 249 aged pulmonary tuberculosis patients with positive sputum culture hospitalized in Shenyang Tenth People’s Hospital from January 1, 2020 to December 31, 2020 were collected. Strains from all the patients were identified as Mycobacterium tuberculosis. A single factor and multiple factors unconditioned logistic regression analysis were used to analyze the risk factors of drug resistance. The total drug resistance rate (TDRR), initial treatment DRR and retreatment DRR were 32.53% (81/249), 24.24% (40/165) and 48.81% (41/84), respectively. The retreatment DRR was significantly higher than initial treatment DRR (χ²=15.307, P=0.000). The total multi-drug resistance rate, initial treatment and retreatment multi-drug resistance rate were 12.85% (32/249), 7.27% (12/165) and 23.81% (20/84), respectively. The multi-drug resistance rate of retreatment was significantly higher than that of initial treatment (χ²=13.591, P=0.000). No extensive drug resistance was found. According to multiple factors logistic regression analysis, retreatment (OR=4.201, 95%CI=1.467-12.033) and tuberculous cavity (OR=2.406, 95%CI=1.019-5.681) were independent risk factors of multidrug-resistance in elderly pulmonary tuberculosis patients. The drug resistance rate of elderly pulmonary tuberculosis was high, the drug resistance screening should be actively carried out.

Key words: Tuberculosis,pulmonary, Aged, Tuberculosis,multidrug-resistant, Factor analysis,statistical

奚莹, 唐军, 乔瑞君, 孙锋, 于艳红. 249例老年肺结核患者耐药状况及产生耐多药的危险因素分析[J]. 中国防痨杂志, 2021, 43(6): 636-641. doi: 10.3969/j.issn.1000-6621.2021.06.020

XI Ying, TANG Jun, QIAO Rui-jun, SUN Feng, YU Yan-hong. Investigation of drug resistance status and risk factors of multidrug-resistance in 249 aged pulmonary tuberculosis patients[J]. Chinese Journal of Antituberculosis, 2021, 43(6): 636-641. doi: 10.3969/j.issn.1000-6621.2021.06.020

图/表 4

表1

表2

表3

表4

参考文献 15

[1]	唐神结, 高文. 临床结核病学. 北京: 人民卫生出版社, 2019: 774, 804-807.
[2]	赵雁林, 逄宇. 结核病实验室检验规程. 北京: 人民卫生出版社, 2015: 32-67.
[3]	《中国防痨杂志》编辑委员会, 中国医疗保健国际交流促进会结核病防治分会基础学组和临床学组. 结核分枝杆菌耐药性检测专家共识. 中国防痨杂志, 2019,41(2):129-137. doi: 10.3969/j.issn.1000-6621.2019.02.003. doi: 10.3969/j.issn.1000-6621.2019.02.003
[4]	中华人民共和国国家卫生和计划生育委员会. WS 196—2017结核病分类. 2017-11-09.
[5]	姜世闻. 重视老年人结核病防治工作. 结核病与肺部健康杂志, 2018,7(3):157-160. doi: 10.3969/j.issn.2095-3755.2018.03.002. doi: 10.3969/j.issn.2095-3755.2018.03.002
[6]	中国防痨协会. 耐药结核病化学治疗指南(2019年简版). 中国防痨杂志, 2019,41(10):1025-1073. doi: 10.3969/j.issn.1000-6621.2019.10.001. doi: 10.3969/j.issn.1000-6621.2019.10.001
[7]	于海娟, 赵梅, 王佳月, 等. 肺结核患者结核杆菌耐药情况及耐多药结核病的危险因素. 中国感染控制杂志, 2020,19(1):58-62. doi: 10.12138/j.issn.1671-9638.20205260. doi: 10.12138/j.issn.1671-9638.20205260
[8]	韩志英, 李静, 张怀庆, 等. 上海市静安区192例肺结核患者结核分枝杆菌耐药状况分析. 中国预防医学杂志, 2019,20(11):1044-1048. doi: 10.16506/j.1009-6639.2019.11.019. doi: 10.16506/j.1009-6639.2019.11.019
[9]	古丽娜·巴德尔, 刘年强, 张风英, 等. 2015年新疆维吾尔自治区结核病耐药监测结果分析. 中国防痨杂志, 2017,39(10):1121-1125. doi: 10.3969/j.issn.1000-6621.2017.10.017. doi: 10.3969/j.issn.1000-6621.2017.10.017
[10]	奚莹, 石莲. 499例肺结核并发糖尿病患者痰培养阳性菌株的耐药状况调查. 中国防痨杂志, 2018,40(6):659-662. doi: 10.3969/j.issn.1000-6621.2018.06.022. doi: 10.3969/j.issn.1000-6621.2018.06.022
[11]	符婷, 黄丽菊, 杨进军, 等. 海南省三亚市158例耐多药肺结核患者危险因素的logistic回归分析. 中国热带医学, 2020,20(8):789-793. doi: 10.13604/j.cnki.46-1064/r.2020.08.22. doi: 10.13604/j.cnki.46-1064/r.2020.08.22
[12]	王彦富, 于艳玲, 王鑫, 等. 耐药肺结核患者相关危险因素分析. 中国公共卫生管理, 2020,36(5):667-670. doi: 10.19568/j.cnki.23-1318.2020.05.017. doi: 10.19568/j.cnki.23-1318.2020.05.017
[13]	Mulu W, Mekonnen D, Yimer M, et al. Risk factors for multidrug resistant tuberculosis patients in Amhara National Regional State. Afr Health Sci, 2015,15(2):368-377. doi: 10.4314/ahs.v15i2.9. doi: 10.4314/ahs.v15i2.9 URL
[14]	GBD Tuberculosis Collaborators. Global, regional, and national burden of tuberculosis, 1990—2016: results from the global burden of diseases, injuries, and risk factors 2016 study. Lancet Infect Dis, 2018,18(12):1329-1349. doi: 10.1016/S1473-3099(18)30625-X. doi: 10.1016/S1473-3099(18)30625-X URL
[15]	Pradipta IS, Forsman LD, Bruchfeld J, et al. Risk factors of multidrug-resistant tuberculosis: a global systematicreview and meta-analysis. J Infect, 2018,77(6):469-478. doi: 10.1016/j.jinf.2018.10.004. doi: 10.1016/j.jinf.2018.10.004 URL

药敏试验结果	初治患者(165例)		复治患者(84例)		合计(249例)
总耐药	40(24.24)		41(48.81)		81(32.53)
任一耐药
INH	25(15.15)		33(39.29)		58(23.29)
RFP	13(7.88)		24(28.57)		37(14.86)
Rfb	5(3.03)		5(5.95)		10(4.02)
Sm	32(19.39)		17(20.24)		49(19.68)
EMB	0(0.00)		3(3.57)		3(1.20)
Pto	1(0.61)		0(0.00)		1(0.40)
PAS	5(3.03)		5(5.95)		10(4.02)
Am	6(3.64)		2(2.38)		8(3.21)
Km	3(1.82)		2(2.38)		5(2.01)
Cm	1(0.61)		1(1.19)		2(0.80)
药敏试验结果		初治患者(165例)		复治患者(84例)	合计(249例)
Lfx		1(0.61)		0(0.00)	1(0.40)
Mfx		0(0.00)		0(0.00)	0(0.00)
Cfz		0(0.00)		0(0.00)	0(0.00)
Cs		0(0.00)		0(0.00)	0(0.00)
Lzd		1(0.61)		2(2.38)	3(1.20)
单耐药		17(10.30)		14(16.67)	31(12.45)
INH		2(1.21)		7(8.33)	9(3.61)
RFP		0(0.00)		2(2.38)	2(0.80)
RFP+Rfb^a		1(0.61)		1(1.19)	2(0.80)
Sm		14(8.48)		3(3.57)	17(6.83)
PAS		0(0.00)		1(1.19)	1(0.40)
多耐药		11(6.67)		7(8.33)	18(7.23)
INH+Sm		6(3.64)		2(2.38)	8(3.21)
RFP+Sm		0(0.00)		1(1.19)	1(0.40)
INH+EMB		0(0.00)		1(1.19)	1(0.40)
INH+Am		0(0.00)		1(1.19)	1(0.40)
INH+Am+Km		1(0.61)		0(0.00)	1(0.40)
INH+PAS+Sm		1(0.61)		0(0.00)	1(0.40)
INH+Km+PAS		1(0.61)		0(0.00)	1(0.40)
INH+Am+PAS+Sm		1(0.61)		0(0.00)	1(0.40)
INH+Km+PAS+Lzd		0(0.00)		1(1.19)	1(0.40)
INH+EMB+Cm+PAS+Lzd		0(0.00)		1(1.19)	1(0.40)
INH+Sm+Pto+Lfx+Am+Cm+Lzd		1(0.61)		0(0.00)	1(0.40)
耐多药		12(7.27)		20(23.81)	32(12.85)
INH+RFP		1(0.61)		7(8.33)	8(3.21)
INH+RFP+Rfb		2(1.21)		2(2.38)	4(1.61)
INH+RFP+Sm		4(2.42)		6(7.14)	10(4.02)
INH+RFP+Rfb+Sm		1(0.61)		2(2.38)	3(1.20)
INH+RFP+Sm+Am		1(0.61)		0(0.00)	1(0.40)
INH+RFP+Sm+Km		0(0.00)		1(1.19)	1(0.40)
INH+RFP+Sm+PAS		0(0.00)		1(1.19)	1(0.40)
INH+RFP+Sm+Am+Km		1(0.61)		0(0.00)	1(0.40)
INH+RFP+Sm+Am+PAS		1(0.61)		0(0.00)	1(0.40)
INH+RFP+Rfb+Sm+PAS		1(0.61)		0(0.00)	1(0.40)
INH+RFP+EMB+Sm+Am+PAS		0(0.00)		1(1.19)	1(0.40)

影响因素	耐多药(32例)		全敏感(168例)		χ²值	P值
影响因素	例数	构成比(%)	例数	构成比(%)	χ²值	P值
性别					0.056	0.813
男性	25	78.12	128	76.19
女性	7	21.88	40	23.81
年龄组(岁)					1.153	0.283
65~74	23	71.88	104	61.90
75~95	9	28.12	64	38.10
居住地					0.390	0.532
城市	20	62.50	95	56.55
农村	12	37.50	73	43.45
吸烟					0.867	0.352
是	15	46.88	64	38.10
否	17	53.12	104	61.90
糖尿病					0.119	0.730
是	8	25.00	47	27.98
否	24	75.00	121	72.02
慢性肺部疾病					0.392	0.531
是	3	9.38	8	4.76
否	29	90.62	160	95.24
体质量指数					1.758	0.185
<18.5	16	50.00	63	37.50
≥18.5	16	50.00	105	62.50
低白蛋白血症(白蛋白<40g/L)					2.174	0.140
是	24	75.00	103	61.31
否	8	25.00	65	38.69
既往规律抗结核治疗					11.578	0.001
是	17	53.12	136	80.95
否	15	46.88	32	19.05
患者类型					16.967	0.000
初治	12	37.50	125	74.40
复治	20	62.50	43	25.60
肺结核空洞					6.332	0.012
有	23	71.88	80	47.62
无	9	28.12	88	52.38
肺部病变范围					0.002	0.968
<3个肺野	6	18.75	31	18.45
≥3个肺野	26	81.25	137	81.55
痰涂片结果					1.153	0.283
阳性	23	71.88	104	61.90
阴性	9	28.12	64	38.10

变量	赋值
既往是否进行规律抗结核治疗	是=1;否=2
患者类型	初治=1;复治=2
是否有肺结核空洞	无=1;有=2

影响因素	β值	$s\bar{x}$值	Wald χ²值	P值	OR值	95%CI值
既往规律抗结核治疗	0.084	0.551	0.023	0.878	1.088	0.370~3.201
复治	1.435	0.537	7.147	0.008	4.201	1.467~12.033
有肺结核空洞	0.878	0.438	4.014	0.045	2.406	1.019~5.681