广西壮族自治区肺结核耐药性调查及复治患者耐药相关因素分析

目的 了解广西壮族自治区（简称“广西”）肺结核耐药现状，探讨影响复治患者耐药产生的因素。 方法2010年8月至2011年7月在广西开展结核病耐药性监测，对14个市采取整群分层抽样方法随机抽取30个结核病防治（简称“结防”）机构门诊为监测点，每个监测点纳入新发涂阳肺结核患者41例、复治涂阳肺结核患者22例。收集复治患者社会和既往临床诊疗信息。收集痰标本培养，培养阳性菌株采用比例法进行异烟肼、利福平、乙胺丁醇、链霉素、卡那霉素、氧氟沙星药敏试验。对硝基苯甲酸(PNB)培养法鉴定结核分枝杆菌复合群。对复治患者社会经济以及既往诊疗因素对耐药的影响进行单因素统计分析。 结果 监测收集到1545例结核分枝杆菌复合群阳性患者，总耐药率17.22%（266/1545）；其中新发涂阳患者耐药率为11.97%（142/1186），复治涂阳患者耐药率为34.54%（124/359），复治患者总耐药率高于新发患者（χ²=98.473，P=0.000）。耐多药率为6.28%(97/1545)；其中新发涂阳患者耐多药率为2.45%（29/1186），复治患者耐多药率为18.94%（68/359），复治患者耐多药率高于新发患者（χ²=127.450，P=0.000）；广泛耐多药率为0.19%（3/1545），全部为复治患者，复治患者广泛耐多药率0.84%（3/359）。复治患者耐药单因素分析表明，女性患者耐药率高于男性（OR=2.009,95%CI:1.145～3.523, χ²=6.062,P=0.014）；壮族患者耐药率高于汉族（OR=1.609,95%CI:1.024～2.529,χ²=4.289, P=0.038）；首次诊疗机构为综合医院的患者耐药率高于到结防机构或专科医院诊疗的患者（OR=1.967,95%CI:1.210～3.198,χ²=7.565, P=0.006）；既往治疗次数2次及以上的患者耐药率高于仅接受过1次治疗的患者（OR=4.128,95%CI:2.506～6.801,χ²=33.160, P=0.000）；非联合用药患者耐药率高于联合用药者（OR=3.419,95%CI:1.952～5.988,χ²=19.775, P=0.000）；低收入家庭患者耐多药率高于高收入患者（OR=4.777,95%CI: 1.117～20.435,χ²=5.336, P=0.021）。 结论 当前广西耐药肺结核疫情仍处于全国较低水平。女性、壮族、低收入、不到定点结防机构诊治、反复多次治疗、不联合用药等可能是导致复治患者耐药的危险因素。

Survey on drug resistant pulmonary tuberculosis and analysis of risk factors to drug resistance of retreatment cases in Guangxi

Objective To explore the status of drug resistant pulmonary tuberculosis and analyze the risk fac- tors contributing to drug resistance of retreatment patients in Guangxi. Methods A prospective survey was con- ducted by consecutively recruiting patients with smear-positive. pulmonary tuberculosis （TB） in 30 TB control insti- tutes from 20]0 to 2011 in Guangxi. Forty-one new cases and 22 retreatment cases were assigned to be recruited in each institute. Information on patient＇s socioeconomic status and previous clinical history was collected by question- naire. Identification of Mycobacterium tuberculosis complex （MTBC） was based on para-nitrobenzoic acid culture test. Drug susceptibility tests （DST） were performed for isoniazid, rifampicin, ethambutol, streptomycin, kanamycin and ofloxacin. Univariate analysis was applied to each variable of patients＇ socioeconomic and clinic information to assess the risk factors associated with drug resistance. Results One thousand five hundred and forty-five isolates collected in the survey were identified as MT]3C. Among them, 17.22% （266/1545） cases were resistant to at least one anti- TB drugs, drug resistant rates of new smear positive cases and retreatment cases were 11.97% （142/1186） and34. 54% （124/359） respectively. The drug resistant rate of retreatment cases was higher than new cases （X^2= 98. 473, P=0. 000）. 6.28% （97/1545） cases were multidrug-resistant tuberculosis （MDR-TB）, 2. 45%（29/1186） for new cases and 68 （18. 94%, 68/359） for cases treated previously. MDR-TB rate was much higher in previous treated cases than new cases （X^2=127. 450, P=0. 000）. 0. 19% （3/1545） of cases was found to be extremely drug- resistant tuberculosis （XDR-TB）, all of whom were retreatment cases （0.84%, 3/359）. Univariate analysis of drug resistance of retreatment cases indicated that female （OR=2. 009, 95%CI： 1. 145-3. 523, X^2= 6. 062, P= 0. 014）, Zhuang nationality （OR=1. 609, 95GCI： 1. 024-2. 529, X^2 =4. 289, P=0. 038）, selecting general hos- pital for first health care seeking （OR= 1. 967, 95 G CI：1. 210-3. 198, Z2 = 7. 565, P = 0. 006）, more than once prior anti-TB treatment （OR= 4. 128, regimerr （OR= 3. 419, 95%CI： 1. 952 95GCI： 2. 506 - 6. 801, X^2 = 33. 160, P= 0. 000）, nonstandard treatment 5. 988, ;X^2 = 19. 775, P=0. 000）, and low family income （OR = 4. 777, 95% CI： 1. 117-20. 435, X^2 =5. 336, P=0. 021） were found to contribute to higher trend of MDR-TB. Conclusion Prevalence of drug resistant TB in Guangxi is lower than the nationat level. Results indicates that female, Zhuang nationality, low family income, seeking health care in non-designated institute and repeated treatment may be the risk factors of drug resistance.