湖南省涂阳肺结核患者结核分枝杆菌耐药谱及其影响因素

目的了解湖南省涂阳肺结核耐药的基本状况、耐药危险因素，为耐药结核病防治提供可靠的参考依据。方法收集2012—2014年湖南省20个结核病专业防治机构确证的1 935株结核分枝杆菌复合群菌株进行药物敏感试验和结果分析，同时对耐药产生的因素进行统计分析。结果1 935株结核分枝杆菌复合群菌株中，1 207株（占62.38%）对6种抗结核药物均敏感，728株耐药株，总耐药率为37.62%；耐多药（MDR）菌467株，MDR率为24.13%，其中广泛耐药(XDR)菌64株，XDR率为3.31%，耐药率由高到低依次为：异烟肼（INH）29.32%、利福平(RFP) 25.84%、链霉素（SM）20.73%、乙胺丁醇（EMB）9.00%、氧氟沙星（OFX）7.83%和卡那霉素（KM）2.21%。多因素logistic 回归分析结果显示：有治疗史、20～39岁和40～60岁组是影响肺结核耐药和MDR的危险因素。复治失败患者INH、RFP、SM、EMB、OFX、KM耐药以及MDR的OR（95%CI）分别为:13.5(9.9～18.4)、21.2(15.2～29.5)、5.3(3.9～7.2)、11.9(7.6～18.7)、7.6(4.6～12.6)、7.9(3.6～17.5)、25.0(17.7～35.1)；复发患者INH、RFP、SM、EMB、OFX耐药以及MDR的OR（95%CI）分别为：7.4(5.5～10.0)、10.3(7.4～14.2)、3.5(2.5～4.8)、7.3(4.5～11.9)、4.1(2.5～6.8)、12.2(8.7～17.1)；初治失败患者INH、RFP、SM、EMB耐药以及MDR的OR（95%CI）分别为： 7.6(4.7～12.3)、9.8(5.9～16.0)、4.1(2.5～6.8)、12.1(6.5～22.7)、11.4(6.9～18.9)。20～39岁组患者INH、RFP、SM耐药及MDR的OR（95%CI）分别为：2.5(1.8～3.4)、3.6(2.5～5.2)、2.9（2.0～4.1）、4.1（2.8～6.1）；40～60岁组INH、RFP、SM耐药及MDR的OR（95%CI）分别为：2.2(1.6～3.0)、3.1(2.2～4.4)、2.3（1.6～3.2）、3.3（2.3～4.7）。结论湖南省涂阳肺结核患者耐药状况比较严重，进行过抗结核治疗会增加患者产生耐药和MDR的风险，20～60岁的患者产生耐药和MDR的风险较高。

Profile and influencing factors of drug resistance of Mycobacterium tuberculosis in smear positive pulmonary tuberculosis patients in Hunan Province

ObjectiveTo investigate status and risk factors of drug resistance of smear positive pulmonary tuberculosis (TB) patients in Hunan Province, and provide reference for the prevention and control of drug resistant TB.Methods1 935 Mycobacterium tuberculosis (MT) complex strains identified by 20 TB prevention and control institutes in Hunan Province between 2012 and 2014 were collected and performed drug susceptibility testing，and influencing factors associated with drug resistance of TB were analyzed statistically.ResultsOf 1 935 MT complex strains, 1 207 （62.38%）were sensitive to 6 kinds of antituberculosis drugs, 728 were drug resistant strains, overall drug resistance rate was 37.62%；467 (24.13%) were multidrug resistant (MDR) strains, 64 of which were extensively drug resistant (XDR) strains, XDR rate was 3.31%, resistance rates from high to low were as follows: isoniazid（INH）29.32%, rifampicin(RFP) 25.84%, streptomycin（SM）20.73%,thambutol（EMB）9.00%, ofloxacin（OFX）7.83%, and kanamycin（KM）2.21%. Multivariate logistic regression analysis showed that patients having a history of treatment, aged 20-39 and 40-60 years old were risk factors for drug resistance and MDR of pulmonary TB. Among patients who failed in retreatment, OR (95% CI) of resistance to INH, RFP, SM, EMB, OFX, KM, and MDR were 13.5(9.9-18.4), 21.2(15.2-29.5), 5.3(3.9-7.2),11.9(7.6-18.7), 7.6(4.6-12.6), 7.9(3.6-17.5), and 25.0(17.7-35.1) respectively; among patients who had recurrence, OR(95% CI) of resistance to INH, RFP, SM, EMB, OFX, and MDR were 7.4(5.5-10.0), 10.3(7.4-14.2), 3.5(2.5-4.8), 7.3(4.5-11.9), 4.1(2.5-6.8), and 12.2(8.7-17.1) respectively；among patients who failed in initial treatment, OR (95% CI) of resistance to INH,RFP,SM,EMB, and MDR were 7.6(4.7-12.3), 9.8(5.9-16.0), 4.1(2.5-6.8), 12.1(6.5-22.7), and 11.4(6.9-18.9) respectively. Among patients aged 20-39 years old, OR (95% CI) of resistance to INH,RFP,SM, and MDR were 2.5(1.8-3.4), 3.6(2.5-5.2), 2.9（2.0-4.1）, and 4.1（2.8-6.1） respectively；among patients aged 40-60 years old, the OR(95% CI) of resistance to INH,RFP,SM, and MDR were 2.2(1.6-3.0),3.1(2.2-4.4),2.3（1.6-3.2）, and 3.3（2.3-4.7）respectively.ConclusionDrug resistance of smear positive pulmonary TB patients is serious in Hunan Province, patients receiving anti tuberculosis treatment and aged between 20-60 years old have high risk for drug resistance and MDR.