妊娠耐多药结核病化学治疗进展

妊娠耐多药结核病的治疗是临床上较为棘手的问题,目前国内外没有统一的方案。笔者对妊娠耐多药结核病的流行病学情况、治疗药物和化疗方案等进展情况进行了综述,为妊娠耐多药结核病患者的治疗提供了一定的参考。     

耐多药和利福平耐药结核病化学治疗研究进展

耐多药结核病(MDR-TB)和利福平耐药结核病(RR-TB)仍然是全球严重的公共卫生问题之一。化学治疗是MDR-TB和RR-TB最重要的治疗手段,但存在治疗周期长、临床疗效差、不良反应多及病死率高等问题,因此,新药研发、优化和改进化疗方案对于提高该病的治愈率和生存率尤为重要。除了已批准上市的新药如贝达喹啉、德拉马尼、利奈唑胺、PA-824外,还有针对MTB的约10余种新化合物正处于不同的临床试验阶段。该病的化疗方案包括长程方案和短程方案,许多国家和地区均开展了不同程度的研究。本文就MDR-TB和RR-TB的化疗进展综述如下。     

耐多药结核病化学治疗的意见(试行)

耐多药结核病的流行已明显影响结核病控制的进程。中国防痨协会于2001年初邀请以下人员:中国防痨协会张立兴主任医师;北京结核病控制研究所屠德华主任医师;上海肺科医院周伯年主任医师、肖和平主任医师;北京结核病胸部肿瘤研究所马研究员;北京胸科医院张培元主任医师;解放军309医院庄玉辉研究员;天津市结核病防治中心王撷秀主任医师;原全国结核病防治中心端木宏瑾主任医师;中国防痨协会蒋建英主任医师等专家经几次讨论提出要写一个关于耐多药结核病治疗的原则性意见,以供全国防痨医务人员参考,并委托肖和平主任起草。期间经几次修改后于2002年4月9日在上海肺科医院周伯平院长的主持下召开了《耐多药结核病化学治疗的意见》定稿会。参加本次会议的专家有肖和平、马、张培元、庄玉辉、屠德华、张立兴、蒋建英等。经反复讨论决定将《耐多药结核病化学治疗的意见》作为中国防痨协会业务文件发表,供全国同道参考、试行,在实践中不断完善。     

耐多药结核病治疗指南的发展趋势

全球结核病发病率在2000—2017年略有下降,但在非洲和亚洲的部分地区仍控制不佳。耐多药结核病(multidrug-resistant tuberculosis,MDR-TB)的治疗现已成为全球公共卫生系统关注的重大问题,国际上对于MDR-TB最适宜的用药和治疗方案尚有争议。笔者总结了近年来WHO关于MDR-TB治疗的指南,对各指南的背景、主要建议、实施情况和发展趋势进行了分析。     

环丝氨酸在耐多药结核病化学治疗中应用价值的探讨

评估环丝氨酸在耐多药结核病化学治疗中的应用价值,为进一步优化中国耐多药结核病化学治疗方案提供依据。     

实施耐多药结核病控制策略遏制耐多药结核病的流行

自20世纪80年代初以来，含利福平和异烟胼的短程化疗方案广泛推行，全球结核病化疗工作取得了重大进展。但随之而产生的一个重要问题是耐利福平和异烟胼的耐多药结核病（MDR-TB）的流行，耐多药结核菌的不断扩散对结核病控制规划的实现构成了严重威胁。     

耐多药结核病进展

概念进展结核病耐药概念的产生是伴随着20世纪50～60年代结核病化疗时代的到来而开始的。从20世纪70年代,陆续出现关于结核病耐药的报道。但是,化疗在结核病控制     

耐多药结核病的研究进展

耐多药结核病(MDR-TR)指患者至少对INH和RFP两药以上产生耐药的结核病人。MDR-TB往往发生在经标准化方案和复治方案反复治疗而失败的患者,且多由患者不规律服药引起。结核分枝杆菌的耐药性是因其作用靶位的突变所致,分枝杆     

耐多药结核病化疗研究的新进展

疗的研究较为深入,其中不乏值得我们借鉴的经验与精髓,仔细拜读,颇有收益,愿与广大同道分享.     

MDR-TB患者采用不同化疗方案所致药物不良反应及治疗转归研究

目的 比较应用不同耐多药结核病化疗方案后患者发生药物不良反应及治疗转归的情况。方法 选取2009年10月至2014年5月在安徽省胸科医院就诊的(包括门诊及住院患者)符合纳入标准并接受治疗的耐多药肺结核患者为研究对象,共102例。将研究对象按照入组时间排序连续随机分配为化疗方案一组(54例)和方案二组(48例)。方案一:3Clr-Z-Am-Mfx+XY/3Clr-Z-Am3-Mfx+XY/12Clr-Z-Mfx+XY;方案二:3Z-Am-Lfx+XY/3Z-Am3-Lfx+XY/18Z-Lfx+XY。其中:Clr:克拉霉素,Z:吡嗪酰胺,Am:阿米卡星(丁胺卡那霉素),Lfx:左氧氟沙星,Mfx:莫西沙星;XY:指根据患者的药物敏感性试验及其耐受情况选择的2种敏感药物(可依次选择:Pto:丙硫异烟胺,PAS:对氨基水杨酸钠,E:盐酸乙胺丁醇)。观察两组患者药物不良反应发生情况及治疗转归情况。结果 方案一组和方案二组治疗成功率分别为59.3%(32/54)和64.6%(31/48),差异无统计学意义(χ ²=0.31,P=0.581)。两种方案药物不良反应发生率分别为66.7%(36/54)和62.5%(30/48),差异无统计学意义(χ ²=0.41,P=0.815)。方案一组药物不良反应发生率居前3位的是胃肠道反应(41.7%,15/36)、单纯性尿酸升高(41.7%,15/36)、血液系统影响(25.0%,9/36);方案二组药物不良反应发生率居前3位的是胃肠道反应(36.7%,11/30)、单纯性尿酸升高(33.3%,10/30)、肝功能损伤(20.0%,6/30)。方案一组有12例(22.2%)患者出现QT间期延长,方案二组有3例(6.3%)患者出现;两种方案比较差异有统计学意义(χ ²=3.97,P=0.046)。方案一组发生药物不良反应及未发生者治疗依从率分别为83.3%(30/36)和88.9%(16/18),差异无统计学意义(χ ²=0.02,P=0.892);方案二组患者治疗依从率分别为83.3%(25/30)和88.9%(16/18),差异无统计学意义(χ ²=0.01,P=0.916)。方案一组发生药物不良反应及未发生者治疗成功率分别为55.6%(20/36)和66.7%(12/18),差异无统计学意义(χ ²=0.61,P=0.433);方案二组患者则分别为60.0%(18/30)和72.2%(13/18),差异无统计学意义(χ ²=0.74,P=0.391)。 结论 两种化疗方案的治疗效果均良好,药物不良反应的发生对患者的治疗依从性及治疗成功率均无影响。     

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.     

Treatment for multidrug-resistant tuberculosis in Japan

INTRODUCTION: Multidrug-resistant (MDR) tuberculosis is now refractory against standard chemotherapy for tuberculosis. The curability of medical treatments for it has been up to 50-75%. In Japan several hundreds new MDR tuberculosis cases are supposed to occur every year. This review is the outline of Japanese preliminary guideline of treatment for MDR tuberculosis. DRUG SUSCEPTIBILITY TEST: One of the most important points to manage MDR tuberculosis is the drug usages according to drug susceptibility. Recently some susceptibility tests with liquid media were introduced in our country, but Japanese new standard test of Ogawa method (using absolute concentration with proportion method) is still important from point of true evaluation of susceptibility. MEDICAL CHEMOTHERAPY: In MDR tuberculosis one-half of two-third cases are cured by suitable resume of anti-tuberculosis chemotherapy. If patients would prove to be suffered from MDR tuberculosis, chemotherapy resume must be changed from standard resume to special one, that are made from effective and stronger four or five (at least three) anti-tuberculosis drugs including new quinolons. Those drugs should be changed at the same time, not one by one. Although CPM and Tb1 cannot be available in Japan, but sometimes we have to try administrations of those drugs, beta-lactam antibiotics, interferon. The duration of treatment will be 18-24 months usually. If decreasing of tuberculosis bacilli in sputa is failed under new effective resume through four months treatment, surgical treatment may be indicated. SURGICAL TREATMENT: (1) In Fukujuji Hospital, Japan Anti-Tuberculosis Association, surgical treatments for seventy four cases of MDR tuberculosis were undergone from 1983 to 2001 March. 85 surgical interventions for them were performed in 71 pulmonary resections (pneumonectomy in 20, lobectomy in 44, segmentectomy in 7) for 64 cases, 8 thoracoplasties alone for 8 cases, 5 cavernostomies for 5 cases, 1 phrenic nerve avulsion for 1. The result of pulmonary resections was as follows; early negative conversion rate of tuberculosis expectorations was 97.2%, reexpectoration rate of sputa tuberculosis bacilli was 13.8%, final success rate of pulmonary resections was 91.7%. The factors significantly correlated to reexpectoration of tuberculosis bacilli were preoperative positive bacilli in sputa, few sensitive drugs, other cavitary lesions remained, postoperative prolonged bronchopleural fistula. The result of thoracoplasty alone revealed 75% success rate. In postoperative complications of 85 interventions, there was no operative death, prolonged bronchopleural fistula in 17.6%, respiratory failure in 8.7%, pyothorax in 5.9%. (2) Recently results of surgical treatment for MDR tuberculosis were reported in several literatures. Those success rates were almost same 85-95% as our result. They seemed to be very excellent for refractory cases against vigorous medical treatments. So any surgical treatment for MDR tuberculosis should be indicated more constructively in its earlier course. (3) Indication of surgical treatment is as follows; Main target lesions that should be removed are cavitary ones in pulmonary or pleural foci. And any capsulated localized tuberculosis foci more than 2 cm in diameter is better to be resected because of the possibility of later cavitation. Surgically it is the best that all tuberculosis foci are within a resected lobe, effective drugs remained as many as possible and no cardiopulmonary risks. But even if patient's state are over those criteria, resections of more extended pulmonary foci including in opposite sides can be tried within tolerable cardiopulmonary function. OTHER COMMENTS: Treatment for HIV-positive MDR tuberculosis and protection for nosocomial transmission of MDR tuberculosis are discussed briefly in this article. Preventive therapy for newly infected persons with MDR tuberculosis is controversial. At this time just in MDR tuberculosis cases no preventive therapy, careful following up, and drastic treatment with remained effective drugs after developping of disease will be recommended.