黑龙江省耐药监测项目中肺结核治疗失败的原因分析

目的分析耐药监测项目中肺结核治疗失败的主要影响因素，为黑龙江省结核病患者的治疗管理提供参考依据。方法对2004年黑龙江省按WHO/IUATLD《结核病耐药监测指南》发现的肺结核患者的指南耐药监测信息和短程督导化疗后的治疗转归信息进行整理分析。结（1）1995例菌阳肺结核中，初治1574例（78.9%）；复治421例（21.1%）。肺结核病患者的耐药情况差异有统计学意义(P)差异有统计学意义（P<0.001)；(2)治疗失败患者的影响因素分析中，除复治是一个主要的影响因素外，初治病例中影响治疗失败的主要因素为居住地（P<0.05调整OR0.36,95%CI0.17-0.76])、耐多药（MDR-TB)(P<0.05调整OR4.70,95%CI1.76-12.51])和痰涂片载量（P<0.05调整OR5.52.95%CI1.84-16.61])；(3)复治患者中影响治疗失败的主要因素为耐多药（P<0.05调整OR5.58，95%CI1.44—21.69])以及复治的次数（P<0.05调整OR3.34，95%CI1.31—8.5])。结论初复治患者间的耐药差异表明在选择治疗方案时应根据药敏试验选择敏感性药物；采用基于一线药的治疗方案在治疗耐药肺结核病方面存在不足，尤其是耐多药患者，确定一个病例耐药之后应根据其药敏结果尽快调整其治疗方案；同时应关注影响治疗失败的危险因素，采取相应措施，减少治疗失败和耐药的产生。

Analysis on treatment failure in drug-resistance surveillance project in Heilongjiang

Objective To learn the drug resistance situation of new and re-treatment TB cases, as well as the influencing factors of treatment failure, and to provide evidence for the case treatment and management in Heilongjiang. Methods The information of treatment and drug-resistance of patients enrolled in the drug resistance surveillance project in 2004 was analyzed. Results （1） There was an significant difference between new and re-treatment patients on drug-resistant （P〈 0. 001） ; （2） The major factors of treatment failure in new cases were place of residence （P〈0.05, adj OR=0.36,95%CI0.17--0.76]）, MDR-TB （P〈0.05,adj OR=4. 70, 95%CI-1.76--12.5]）, and high sputum smear load （P〈0.05, adj OR=5.52, 95% CI1. 84--16. 61]） ; （3） The main factorsof treatment failure in re-treated patients were MDR-TB （P〈0.05, adj OR=5.58, 95%CI -1.44--21. 693）, and the times of re-treatment （P%0.05, adj OR=3.34, 95%CI-1.31--8.5%）. Conclusions The difference of drug resistance between new and re-treatment patients shows that chemotherapy should be chosen based on the result of drug sensitivity test; these data suggest that standard short-course chemotherapy, based on first-line drugs, is inadequate for some patients, es- pecially MDR-TB cases. Besides, the risk factors of treatment failure should be concerned to im- prove the measures of management and treatment and to reduce the emergence of treatment failure and drug resistance.