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中国防痨杂志 ›› 2021, Vol. 43 ›› Issue (10): 1010-1015.doi: 10.3969/j.issn.1000-6621.2021.10.007

• 论著 • 上一篇    下一篇

分子药物敏感性试验对复治涂阳肺结核患者化疗的指导及效果分析

刘轾彬, 吴敏, 吴小翠, 韩敏, 张青, 沙巍()   

  1. 200433 同济大学附属上海市肺科医院结核科(刘轾彬、吴敏、张青、沙巍),检验科(吴小翠、韩敏)
  • 收稿日期:2021-06-07 出版日期:2021-10-10 发布日期:2021-10-11
  • 通信作者: 沙巍 E-mail:shfksw@126.com
  • 基金资助:
    “十三五”国家科技重大专项(2018ZX10722302-002);上海市感染性疾病(结核病)临床医学研究中心项目(19MC1910800)

Individualized treatment for retreatment smear-positive pulmonary tuberculosis patients based on molecular drug susceptibility testing and its short-term effectiveness

LIU Zhi-bin, WU Min, WU Xiao-cui, HAN Min, ZHANG Qing, SHA Wei()   

  1. Department of Tuberculosis, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai 200433, China
  • Received:2021-06-07 Online:2021-10-10 Published:2021-10-11
  • Contact: SHA Wei E-mail:shfksw@126.com

摘要:

目的 评价分子药物敏感性试验(简称“药敏试验”)对复治涂阳肺结核患者化疗的指导及效果。方法 采用前瞻性随机对照的方法,选取2016年3月至2020年1月上海市肺科医院诊治的400例复治涂阳肺结核患者作为研究对象,收集患者的痰液或支气管肺泡灌洗液行分枝杆菌培养,培养阳性且鉴定为MTB的分离株采用微孔板法进行表型药敏试验;按就诊时间顺序依随机数字表法对其中200例患者的同一份标本采用PCR-反向点杂交法进行分子药敏试验,检测异烟肼和利福平耐药相关基因。微孔板法结果回报前,PCR-反向点杂交法检测为异烟肼和(或)利福平耐药的患者予异烟肼和(或)利福平耐药化疗方案,其余患者予异烟肼、利福平敏感复治化疗方案;微孔板法结果回报后,以微孔板法结果为标准调整化疗方案。比较微孔板法确诊的利福平耐药患者中行PCR-反向点杂交法者与未行PCR-反向点杂交法者在微孔板法结果回报时的痰涂片抗酸杆菌阴转率和痰涂片阳性标本荷菌量,以及在应用耐药方案治疗3、6、9、12个月末的痰菌阴转率。结果 在微孔板法确诊的利福平耐药患者中,行PCR-反向点杂交法与未行PCR-反向点杂交法的患者在微孔板法结果回报时的痰涂片抗酸杆菌阴转率分别为18.9%(10/53)和5.9%(3/51),差异有统计学意义(χ2=4.007,P=0.045);行PCR-反向点杂交法患者痰涂片阳性标本抗酸杆菌分级计数“+、++、+++、++++”分别占48.8%(21/43)、25.6%(11/43)、16.3%(7/43)、9.3%(4/43),未行PCR-反向点杂交法患者分级计数分别占16.7%(8/48)、35.4%(17/48)、33.3%(16/48)、14.6%(7/48),差异有统计学意义(χ2=11.212,P=0.011),前者痰标本荷菌量更少。行PCR-反向点杂交法的患者治疗3、6、9、12个月末的痰菌阴转率分别为64.0%(32/50)、84.8%(39/46)、82.9%(34/41)、84.2%(32/38),高于未行PCR-反向点杂交法的患者治疗3、6、9、12个月末的痰菌阴转率[分别为58.8%(30/51)、81.0%(34/42)、81.6%(31/38)、81.6%(31/38)],差异均无统计学意义(χ2=0.285,P=0.593;χ2=0.593,P=0.218;χ2=0.025,P=0.874;χ2=0.093,P=0.761)。结论 复治涂阳肺结核患者中根据PCR-反向点杂交法制定化疗方案的利福平耐药患者能在时间上更早获得痰涂片抗酸杆菌阴转率的上升和痰涂片阳性标本荷菌量的下降。

关键词: 结核, 肺, 再治疗, 微生物敏感性试验, 药物疗法, 疗效比较研究

Abstract:

Objective To evaluate individualized treatment of retreatment smear-positive pulmonary tuberculosis (PTB) patients based on molecular drug susceptibility testing (DST) and its short-term effectiveness. Methods A prospective, randomized and controlled study was conducted, and 400 retreatment PTB patients diagnosed and treated in Shanghai Pulmonary Hospital from March 2016 to January 2020 were enrolled. Sputum or bronchoalveolar lavage fluid of each patient was collected and cultured for mycobacterium. Then strains which were isolated from positive culture and identified as Mycobacterium tuberculosis were tested for phenotypic DST using Micropore-plate method (MicroDST). Meanwhile, 200 patients were randomly selected according to visiting time sequence and random number table, specimen of those patients were tested for molecular DST using PCR-reverse dot blot (RDB) hybridization, thus drug resistance related genes of isoniazid (H) and rifampicin(R) were detected. Before the results of MicroDST were reported, patients with H and (or) R resistance detected by PCR-RDB were treated with H- and (or) R-resistant chemotherapy regimen, while other patients were treated with H- and R-susceptible retreatment chemotherapy regimen; after the results of MicroDST were reported, the chemotherapy regimens of all patients were adjusted according to the results of MicroDST. The sputum smear negative conversion rates and bacterial load of smear-positive specimen at the time of MicroDST results being reported, and the sputum smear negative conversion rates at the end of 3, 6, 9 and 12 months after drug-resistant chemotherapy started, were compared between patients with PCR-RDB and patients without PCR-RDB among rifampicin-resistant patients diagnosed by MicroDST. Results For patients with PCR-RDB and patients without PCR-RDB among rifampicin-resistant patients diagnosed by MicroDST, the sputum smear negative conversion rates at the time of MicroDST results being reported were 18.9% (10/53) and 5.9% (3/51) respectively, the difference was statistically significant (χ2=4.007, P=0.045); the graded counts ”+, ++, +++, ++++” of acid-fast bacilli in smear-positive specimens of patients with PCR-RDB were 48.8% (21/43), 25.6% (11/43), 16.3% (7/43) and 9.3% (4/43), while for patients without PCR-RDB were 16.7% (8/48), 35.4% (17/48), 33.3% (16/48) and 14.6% (7/48) at the time of MicroDST results being reported, the difference of smear positive grading was significant statistically (χ2=11.212, P=0.011), and sputum bacterial load of smear-positive specimen of the former was lower. Sputum negative conversion rates of patients with PCR-RDB at the end of 3, 6, 9 and 12 months after treatment with rifampicin-resistant chemotherapy regimen were 64.0% (32/50),84.8% (39/46), 82.9% (34/41),84.2% (32/38), higher than those of patients without PCR-RDB (58.8% (30/51), 81.0% (34/42), 81.6% (31/38), 81.6% (31/38)), all differences were not statistically significant (χ2=0.285,P=0.593;χ2=0.593,P=0.218;χ2=0.025,P=0.874;χ2=0.093,P=0.761). Conclusion Patients treated with rifampicin-resistant chemotherapy regimen based on PCR-RDB could have sputum smear negative conversion rate increasing and sputum bacteria load decreasing earlier among retreatment smear-positive PTB patients diagnosed by MicroDST.

Key words: Tuberculosis, pulmonary, Retreatment, Microbial sensitivity tests, Drug therapy, Comparative effectiveness research