Lung resection for multidrug-resistant tuberculosis

The emergence of multidrug-resistant tuberculosis poses a serious challenge to traditional drug therapy. In view of the relapse rate of up to 50% following medical management, there has been renewed interest in the role of surgery for this problem. We report our experience with lung resection for this condition. Over a 5-year period, resection was performed in 23 patients who were diagnosed with multidrug resistance after completing a course of standard chemotherapy and at least 3 months of second-line therapy. Pneumonectomy was performed in 17 patients and lobectomy in 6. There was no operative or postoperative mortality. Major complications developed in 4 patients (17.4%): 2 had post-pneumonectomy empyema and 2 underwent rethoracotomy for bleeding. Ten patients were sputum positive preoperatively, and only 1 remained positive after surgery. The patients were put on appropriate chemotherapy and followed up for 18 months. The cure rate was 95.6%. Pulmonary resection can be considered as an important adjunct to medical therapy in carefully selected patients: those who have localized disease with adequate pulmonary reserve, or who have multiple previous relapses, or whose sputum remains positive after 4 to 6 months of appropriate medical treatment. Surgery offers high cure rates with acceptable morbidity and mortality.     

Pulmonary resection in the treatment of patients with pulmonary multidrug-resistant tuberculosis in Taiwan.

SETTING: Chronic Disease Control Bureau, Department of Health, Taiwan. OBJECTIVE: To evaluate the role of pulmonary resection in the treatment of pulmonary tuberculosis resistant to isoniazid and rifampin (MDR-TB). DESIGN: In a retrospective cohort study, 27 MDR-TB patients who underwent pulmonary resection between December 1990 and March 1999 were reviewed. Individually-tailored treatment regimens were selected at a once-weekly staff conference following review of the patient's case history and drug susceptibility results. Surgery was performed for selected patients, essentially those: 1) whose medical treatment had failed, or for whom treatment failure seemed highly likely, or for whom post-treatment relapse seemed likely, 2) with predominantly localised disease, 3) with adequate cardiopulmonary reserve, and 4) whose treatment regimen had been composed of at least two effective drugs to diminish the mycobacterial burden. RESULTS: There was no surgical mortality apart from one peri-operative death (4%). Three patients (11%) developed complications, and 24 (92%) patients demonstrated sputum conversion and/or remained negative after surgery. Twenty-three patients have already completed treatment, and during a mean of 42 +/- 18 follow-up months (range 15-80 months), one patient relapsed. This patient was disease-free after another course of treatment. CONCLUSION: For selected patients, pulmonary resection may improve the outcome of pulmonary MDR-TB.     

A retrospective study for the outcome of pulmonary resection in 49 patients with multidrug-resistant tuberculosis.

BACKGROUND: Outcome of treatment using only chemotherapy for multidrug-resistant tuberculosis is usually considered not to be satisfactory. The combination of chemotherapy with surgical treatment has been producing higher acid-fast bacilli (AFB) negative sputum conversion and longer survival rates. This treatment strategy may be the solution for patients with multidrug-resistant tuberculosis. MATERIALS AND METHODS: A retrospective review was performed of the medical records and laboratory findings of 49 patients with multidrug-resistant tuberculosis among 130 patients who underwent pulmonary resection for pulmonary tuberculosis between January 1995 and December 1999 at National Masan Tuberculosis Hospital, Korea. RESULTS: The mean number of drugs to which the patients were resistant was 4.5. Patients had a mean age of 35 years. Cavitary lesions on plain chest X-ray were shown in 43/49 patients (87.8%); 31 had positive sputum cultures preoperatively (63.3%). The surgical techniques used were as follows: 12 pneumonectomies, 28 lobectomies, seven lobectomies with segmentectomies or wedge resections, one wedge resection and one cavernoplasty. The AFB negative sputum conversion rate was 93.5% with continuous postoperative chemotherapy. There were no deaths after surgery. Postoperative complications that developed were six cases of air leakage over a week, one of postoperative bleeding and one of wound infection. CONCLUSIONS: This study demonstrated the effectiveness of pulmonary resection with postoperative chemotherapy in cases of multidrug-resistant tuberculosis. Although there are different ideas about indications for surgery and the length and content of postoperative drug regimens, pulmonary resection should be considered an effective measure in combination with chemotherapy for treatment of multidrug-resistant pulmonary tuberculosis.     

Costs of patients hospitalized for multidrug-resistant tuberculosis.

SETTING: From 1993 through 1998, 1846 cases of multidrug-resistant tuberculosis (MDR-TB) were reported in the United States. Costs associated with MDR-TB are likely to be much higher than for drug-susceptible tuberculosis due to longer hospitalization, longer treatment with more expensive and toxic medications, greater productivity losses, and higher mortality. OBJECTIVE: To measure the societal costs of patients hospitalized for MDR-TB. DESIGN: We detailed in-patient costs for 13 multidrug-resistant patients enrolled in a national study. We estimated costs for physician care, out-patient treatment, and productivity losses for survivors and for deceased patients. RESULTS: In-patient costs averaged US$25,853 per person and $1036 per person-day of hospitalization. Outpatient costs per person ranged from $5744 to $41,821 (average $19028, or $44 a day). Direct medical costs averaged $44,881; indirect costs for those who survived averaged $32,964, and indirect costs for those who died averaged $686,381 per person. Total costs per person ranged from $28,217 to $181492 (average $89,594) for those who survived, and from $509490 to $1278066 (average $717555) for those who died. CONCLUSION: The societal costs of MDR-TB varied, mostly because of length of therapy (including in-patient), and deaths during treatment.     

Risk factors for multidrug-resistant tuberculosis in Hong Kong

SETTING: Previous anti-tuberculosis treatment is a widely reported risk factor for multidrug-resistant tuberculosis (MDR-TB), whereas other risk factors are less well described. In Hong Kong, the clinical characteristics of MDR-TB have not been systematically evaluated. OBJECTIVE: To explore the risk factors for MDR-TB in Hong Kong. DESIGN: MDR-TB patients treated between 1999 and 2003 were compared with non-MDR-TB patients by stratification of previous anti-tuberculosis treatment. RESULTS: One hundred and fifty-six MDR-TB patients, including 93 with and 63 without a previous history of anti-tuberculosis treatment, were identified. Among the 322 non-MDR-TB controls, respectively 192 and 130 patients did and did not have a previous history of anti-tuberculosis treatment. Using logistic regression analysis, non-permanent residents (OR 6.85, 95%CI 1.38-34.09), frequent travel (OR 2.48, 95%CI 1.07-5.74) and younger age were found to be independent predictors of MDR-TB in previously treated patients, whereas living on financial assistance just failed to reach statistical significance (OR 2.75, 95%CI 0.98-7.68, P=0.05). In the treatment-na?ve group, despite significant differences in baseline characteristics among MDR-TB and non-MDR-TB patients, no independent predictor variables could be identified. CONCLUSION: In Hong Kong, non-permanent residents, frequent travel and young age were independent predictors of MDR-TB among previously treated patients.     

产生耐多药结核病50例的危险因素分析

目的探讨产生耐多药结核病的危险因素。方法病例组为50例耐多药结核患者,对照组为50例非耐药结核患者,采用卡方检验和非条件Logistic回归进行分析。结果卡方分析有统计学意义(P0.05)的变量有体重指数(BMI)、居住地、饮酒、服药规律性、结核病史、肺结核空洞病灶;非条件logistic回归分析有统计学意义的变量有饮酒、服药规律性、结核病史和肺结核空洞病灶,OR值分别为0.211、0.442、2.468、6.150。结论不规律服药、结核病史和肺结核空洞病灶是产生耐多药结核病的危险因素,应采取相对应措施控制产生耐多药结核病。     

耐多药肺结核治愈患者复发的影响因素分析

目的:分析耐多药肺结核(multidrug-resistant pulmonary tuberculosis,MDR-PTB)患者治愈后复发的危险因素。方法:采用回顾性研究方法,搜集2013年1月至2017年12月期间来自全国15个省份的18家医院的经长程(18~24个月)化疗方案(6Am-Lfx-P-Z-Pto/18Lfx-P-Z-Pto;Am:阿米卡星,Lfx:左氧氟沙星,P:对氨基水杨酸钠,Z:吡嗪酰胺,Pto:丙硫异烟胺)治愈并随访3年的600例MDR-PTB患者作为研究对象。收集研究对象的基本信息、临床信息和实验室检测结果,包括性别、年龄、体质量指数、慢性病病史、结核病病史(接受本长疗程化疗方案前)、治疗用药情况,以及痰涂片、痰培养、药物敏感性试验、胸部CT扫描、血常规、血红细胞沉降率、尿常规、肝肾功能等资料。分析MDR-PTB患者治愈后复发的危险因素,并通过受试者工作特征曲线评价复发危险因素对MDR-PTB复发的预测价值。结果:600例研究对象,治愈后随访3年,发现有40例复发,复发率为6.7%(40/600;95%CI:4.9%~9.1%)。多因素logistic回归分析结果显示:血红细胞沉降率升高[OR(95%CI)=2.705(1.136~6.444)]、总胆红素水平升高[OR(95%CI)=5.329(1.408~20.170)]、尿蛋白水平升高[OR(95%CI)=5.642(1.650~19.292)]、尿糖水平升高[OR(95%CI)=5.333(1.357~20.954)]、使用环丝氨酸[OR(95%CI)=11.771(3.920~35.347)]、肺结核初次诊断到MDR-PTB初次诊断时间≥1年[OR(95%CI)=8.730(2.710~28.119)]、有空洞[OR(95%CI)=32.806(6.096~176.557)]是MDR-PTB复发的独立危险因素。受试者工作特征曲线分析显示,以logistic回归分析总体模型为检验变量时,曲线下面积最大(0.932)。结论:应重点关注血红细胞沉降率、总胆红素水平、尿蛋白水平、尿糖水平高于正常值范围,以及肺结核初次诊断到MDR-PTB初次诊断时间≥1年和合并空洞MDR-PTB患者的治疗和随访,并合理规范使用环丝氨酸。     

Psychiatric issues in the management of patients with multidrug-resistant tuberculosis.

INTRODUCTION: Psychiatric issues present a challenge in the treatment of patients with multidrug-resistant tuberculosis (MDR-TB). Both baseline psychiatric disorders and development of psychiatric complications related to anti-tuberculosis drugs and psychosocial factors require aggressive management. SETTING: A community-based non-governmental health organization in Lima, Peru. OBJECTIVE: To review the literature for psychiatric complications associated with anti-tuberculosis medications, to describe the incidence and prevalence of depression, anxiety and psychosis among individuals receiving MDR-TB therapy, and to detail the management approach used in this cohort. METHODS: A retrospective case series was performed among the first 75 patients to receive individualized MDR-TB therapy in Lima, Peru, between 1996 and 1999. RESULTS: Baseline depression and baseline anxiety were observed in respectively 52.2% and 8.7% of this cohort. Most individuals with baseline depression experienced improvement of depressive symptoms during the course of TB therapy. The incidence of depression, anxiety and psychosis during MDR-TB treatment was 13.3%, 12.0% and 12.0%, respectively. While the majority of individuals with depression, anxiety and psychosis required psychiatric pharmacotherapy, cycloserine was successfully continued in all but one case. CONCLUSION: Psychiatric comorbidities are not a contra-indication to MDR-TB therapy. Management of psychiatric complications is possible without compromising anti-tuberculosis treatment.     

耐多药肺结核患者治疗结果及其影响因素调查

目的了解耐多药肺结核患者的治疗结果及其影响因素。方法对纳入项目治疗的患者进行问卷调查,并将相关结果进行病例对照研究。结果 70例接受耐多药治疗的患者中,32例治愈,1例完成疗程;多因素logistic回归分析,年龄>38岁和耐多药治疗前累计服药>15个月是患者未治愈的主要危险因素。结论规范二线药物使用,前移耐多药检测关口和加强患者的治疗管理,对具有治疗失败高风险患者进行个体化调整。     

老年结直肠癌术后长期生存的预后因素分析

目的:探索影响老年结直肠癌术后长期生存的相关因素。方法:回顾性分析SEER数据库中2004年登记注册诊断为(CRC)术后(年龄≥60岁)的病例,有随访10年以上存活记录。采用 Cox比例风险模型评估年龄,性别,种族,婚姻状况,肿瘤部位和大小,临床分期,TNM分期,淋巴结清除范围等对生存死亡的预后风险。 ...     

Determination of risk factors for isoniazid monoresistance and multidrug-resistant tuberculosis in treatment failure patients

India has a high number of drug-resistant tuberculosis cases. Patient records were screened to determine risk factors possibly associated with monoresistance and multidrug-resistant tuberculosis (MDR-TB) in comparison with patients with susceptible TB. We retrospectively screened and selected 250 patient records from a tertiary care centre, in which detailed clinical histories were provided. Of the 250 patients, 10 had isoniazid monoresistant TB, 184 patients had MDR-TB, and 56 patients had TB susceptible to first-line drugs. Binary regression analysis revealed that previous treatment with a fluoroquinolone and an injectable other than streptomycin (odds ratio (OR) 3.889, 95% confidence interval (CI) 1.828-8.272) was associated with MDR-TB. Previous history of TB (OR 0.697, 95% CI 0.363-1.338) and the presence of cavities on radiographs (OR 0.371, 95% CI 0.160-0.862) did not show any association. None of these reported risk factors were associated with isoniazid monoresistance. In conclusion, a history of previous treatment with a fluoroquinolone and an injectable other than streptomycin was found to be a risk factor for MDR-TB.     

Management of multidrug-resistant tuberculosis and patients in retreatment.

Retreatment of tuberculosis involves the management of entities as diverse as relapse, failure, treatment after default, and poor patient adherence to the previous treatment. The emergence of conditions for selection of resistance (failure and partial abandonment) is a matter of great concern. The development of a retreatment regimen for tuberculosis requires consideration of certain basic premises. The importance of a comprehensive and directed history of drugs taken in the past, and the limited reliability of susceptibility tests to many of these drugs, should be kept in mind. Taking this into account, and possessing a thorough knowledge of all anti-tuberculosis medications, it is possible to cure almost all patients with an appropriate retreatment regimen including a minimum of three or four drugs not previously used. Nonetheless, the treatment of these patients is so complex that it should only be carried out by experienced staff. Concern about treating tuberculosis patients with drug resistance varies greatly depending on the available resources. High-income countries should provide individual treatment regimens adapted to each patient; however, in other settings, restricted resources could justify the implementation of standardised therapeutic guidelines with second-line drugs in order to facilitate management and reduce costs.     

Risk factors for nosocomial transmission of multidrug-resistant tuberculosis due to Mycobacterium bovis among HIV-infected patients.

OBJECTIVE: To identify risk factors for transmission of multidrug-resistant tuberculosis (MDR-TB) among hospitalized human immunodeficiency virus (HIV) infected patients exposed during a nosocomial outbreak. DESIGN: Case control study. Cases were HIV-infected patients with MDR-TB due to Mycobacterium bovis (MDR-TBMb) who acquired the disease after exposure to an MDR-TBMb patient in an hospital ward. Controls were HIV-infected patients exposed to a case of MDR-TBMb in an hospital ward but who did not develop MDR-TBMb during the follow-up. RESULTS: Nineteen cases and 31 controls were included. CD4 cell counts were significantly lower among cases. Exposure in the infectious diseases ward or exposure to the index patient were associated with development of MDR-TBMb, while exposure during a single-room hospital stay and exposure in the respiratory isolation ward were associated with non-development of MDR-TBMb. A multiple regression logistic model showed that only a CD4 cell count below 50/microL and exposure to the index patient increased the risk of developing MDR-TBMb (P < 0.05). Hospitalization in a single room seemed to protect HIV-infected patients from developing nosocomial MDR-TBMb (P = 0.052). CONCLUSIONS: Over classic risk factors, such as length of exposure or sharing a room with a case, severe immunosuppression independently increases the risk of MDR-TB transmission in the context of a nosocomial MDR-TB outbreak among HIV-infected patients. This information must be considered in the management of tuberculosis outbreaks. Patients with CD4 cell counts below 50/microL should be the principal group targeted for prevention strategies in nosocomial outbreaks.     

“LTB-S”分类法与耐多药肺结核手术适应证探讨

目的 探讨“LTB-S”分类法在耐多药肺结核手术适应证方面的价值,以减少肺结核患者的手术并发症和医疗费用。 方法 以中华医学会结核病学分会的《临床技术操作规范结核病分册》为依据,建立一套简单实用的“LTB-S”最佳手术时机判断系统,将耐多药肺结核外科手术患者分为Ⅰ类（绝对手术适应证）、Ⅱ类（相对手术适应证）、Ⅲ类（无手术适应证）。同时选择现有的已手术的27例肺结核手术患者进行验证分析。 结果 27例患者中,Ⅰ类8例,Ⅱ类17例,Ⅲ类2例,符合“LTB-S”最佳手术时机判断原则的Ⅰ类患者无并发症发生,Ⅱ类和Ⅲ类患者各出现2例手术并发症,其中Ⅲ类患者手术并发症发生率100%（2/2）。随访4个月至12年,2例Ⅲ类患者未治愈,其余患者均治愈。 结论 LTB-S判断系统有助于耐多药肺结核患者最佳手术适应症的判断,具有实用的临床价值,适宜在临床中推广应用。     

耐多药肺结核患者生命质量及其影响因素分析

目的 了解耐多药肺结核(MDR-TB)患者的生命质量,并分析其影响因素。方法 收集云南省2012—2015年在《结核病管理信息系统》中登记治疗管理的46例MDR-TB患者(MDR-TB组),采用1∶1配比病例对照研究,选取在这期间该系统登记治疗管理的对抗结核药物治疗敏感的肺结核患者46例作为对照组。采用横断面调查的方法,用《慢性病患者生命质量测定量表》中的《肺结核患者生命质量测定量表》(Quality of Life Instruments for Chronic Disease-Pulmonary Tuberculosis)测量并比较两组患者的生命质量,用多重线性回归分析法分析影响MDR-TB患者生命质量的因素。结果 MDR-TB组患者生命质量总得分、生理功能得分、心理功能得分、社会功能得分分别为(152.11±17.04)分、(35.85±5.53)分、(39.65±6.84)分、(29.52±4.92)分,低于对照组患者的(169.28±24.05)分、(41.39±5.53)分、(44.59±6.24)分、(32.91±5.66)分,差异均有统计学意义(t值分别为3.95、4.81、3.62、3.07,P值均<0.05);多重线性回归分析显示,MDR-TB患者生命质量的影响因素为治疗持续时间(β=15.17,t=2.28,P=0.028);46例MDR-TB患者治疗前生命质量得分为(139.33±12.86)分,治疗中得分为(151.75±16.56)分,治疗后得分为(169.67±17.67)分,MDR-TB患者生命质量随着治疗时间的延长而提高。结论 MDR-TB患者生命质量低于对抗结核药物治疗敏感的肺结核患者,治疗持续时间是MDR-TB患者生命质量可能的影响因素。