Article(id=1198196210768118359, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198196207379120715, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.0338.2024.0731, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1710518400000, receivedDateStr=2024-03-16, revisedDate=null, revisedDateStr=null, acceptedDate=1714233600000, acceptedDateStr=2024-04-28, onlineDate=1763601838056, onlineDateStr=2025-11-20, pubDate=1735315200000, pubDateStr=2024-12-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1763601838056, onlineIssueDateStr=2025-11-20, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1763601838056, creator=13701087609, updateTime=1763601838056, updator=13701087609, issue=Issue{id=1198196207379120715, tenantId=1146029695717560320, journalId=1189873630562394117, year='2024', volume='49', issue='12', pageStart='1343', pageEnd='1459', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1763601837248, creator=13701087609, updateTime=1763603898104, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1198204851306988030, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198196207379120715, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1198204851306988031, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198196207379120715, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1379, endPage=1385, ext={EN=ArticleExt(id=1198196211166577249, articleId=1198196210768118359, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Analysis of drug resistance in disseminated pulmonary tuberculosis: 71 cases report, columnId=1190310109000602400, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Clinical Research, runingTitle=null, highlight=null, articleAbstract=

Objective To analyze the characteristics of drug resistance in patients with disseminated pulmonary tuberculosis, and provide references for the clinical development of individualized treatment plans. Methods A retrospective analysis was conducted on 71 hospitalized patients with disseminated pulmonary tuberculosis treated at the Beijing Chest Hospital, Capital Medical University from January 2015 to January 2024. The susceptibility of Mycobacterium tuberculosis from these patients to 16 anti-tuberculosis drugs was detected using the microplate method for mycobacterial drug susceptibility testing. The study analyzed the culture results of Mycobacterium tuberculosis, drug susceptibility test results, initial treatment or re-treatment status, drug resistance, and differences in drug resistance types between initial and re-treated patients. Results Among the 71 patients with disseminated pulmonary tuberculosis, there were 51 males (71.8%), and 58 cases (81.7%) of acute disseminated pulmonary tuberculosis, with an overall drug resistance rate to 16 anti-tuberculosis drugs of 38.0%. There was no statistically significant difference in the total drug resistance rate between re-treated patients and those undergoing initial treatment [52.2%(12/23) vs. 31.3%(15/48), P=0.089]. The top 7 drugs to which patients were resistant were streptomycin (Sm) and isoniazid (INH) with 13 cases each (18.3%), rifapentine (Rft) and isoniazid aminosalicylate (Pa) with 10 cases each (14.1%), rifampicin (RFP), rifabutin (Rfb), and capreomycin (Cm) with 9 cases each (12.7%). The top 6 drugs to which initially treated patients were resistant were Cm with 6 cases (12.5%), Sm with 5 cases (10.4%), Pa with 4 cases (8.3%), INH, clarithromycin (Clr), and p-aminosalicylic acid (PAS) with 3 cases each (6.3%). The top 7 drugs to which re-treated patients were resistant were INH with 10 cases (43.5%), Sm, RFP, and Rft with 8 cases each (34.8%), Rfb with 7 cases (30.4%), Pa and levofloxacin (Lfx) with 6 cases each (26.1%). The overall mono-resistance rate, poly-drug resistance rate, and multidrug-resistant rate to 16 anti-tuberculosis drugs were 9.9%, 7.0%, and 11.3%, respectively; all mono-resistance patients were initially treated; there was no statistically significant difference in the poly-drug resistance rate between re-treated and initially treated patients (13.0% vs. 4.2%, P=0.591), but the multidrug-resistant rate was significantly higher in re-treated patients (30.4% vs. 2.1%, P=0.002). Conclusion Drug resistance in disseminated pulmonary tuberculosis is severe. Clinical physicians can develop personalized anti-tuberculosis treatment plans based on drug susceptibility test results.

, correspAuthors=Gui-Rong Wang, authorNote=null, correspAuthorsNote=
E-mail:
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目的 分析血行播散性肺结核患者的耐药特点,为临床制定个体化治疗方案提供参考。方法 回顾性分析2015年1月-2024年1月首都医科大学附属北京胸科医院收治的71例血行播散性肺结核住院患者的临床资料。采用分枝杆菌微孔板药敏检测技术检测来自71例患者的结核分枝杆菌对16种抗结核药的敏感性,分析血行播散性肺结核患者的结核分枝杆菌培养结果、药敏试验结果、初治或复治情况、耐药情况,以及初治与复治患者耐药类型的差异。结果 71例血行播散性肺结核患者中,男51例(71.8%),急性血行播散性肺结核58例(81.7%),对16种抗结核药的总耐药率为38.0%。复治患者总耐药率与初治患者比较差异无统计学意义[52.2%(12/23) vs. 31.3%(15/48),P=0.089]。患者对16种抗结核药任一耐药的前7位为链霉素(Sm)、异烟肼(INH)各13例(18.3%),利福喷丁(Rft)、对氨基水杨酸异烟肼(Pa)各10例(14.1%),利福平(RFP)、利福布汀(Rfb)、卷曲霉素(Cm)各9例(12.7%);初治患者任一耐药的前6位为Cm 6例(12.5%),Sm 5例(10.4%),Pa 4例(8.3%),INH、克拉霉素(Clr)、对氨基水杨酸(PAS)各3例(6.3%);复治患者任一耐药的前7位为INH 10例(43.5%),Sm、RFP、Rft各8例(34.8%),Rfb 7例(30.4%),Pa、左氧左旋氧氟沙星(Lfx)各6例(26.1%)。患者对16种抗结核药的总单耐药率、总多耐药率、总耐多药率分别为9.9%、7.0%、11.3%;所有单耐药患者均为初治患者;复治患者多耐药率与初治患者比较差异无统计学意义[13.0% vs. 4.2%,P=0.591],但耐多药率明显高于初治患者[30.4% vs. 2.1%,P=0.002]。结论 血行播散性肺结核耐药情况严峻,临床医师可根据药敏试验结果制定个性化的抗结核治疗方案。

, correspAuthors=王桂荣, authorNote=null, correspAuthorsNote=
王桂荣,E-mail:
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施亦衡,硕士研究生,主要从事结核病诊断新技术及相关机制的研究

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施亦衡,硕士研究生,主要从事结核病诊断新技术及相关机制的研究

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Medicina (Kaunas), 2023, 59(2): 246., articleTitle=Management of polydrug-resistant tuberculosis, refAbstract=null), Reference(id=1198318901168795916, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, doi=null, pmid=null, pmcid=null, year=2019, volume=41, issue=2, pageStart=129, pageEnd=137, url=null, language=null, rfNumber=[39], rfOrder=38, authorNames=《中国防痨杂志》编辑委员会, 中国医疗保健国际交流促进会结核病防治分会基础学组和临床学组, journalName=中国防痨杂志, refType=null, unstructuredReference=《中国防痨杂志》编辑委员会, 中国医疗保健国际交流促进会结核病防治分会基础学组和临床学组. 结核分枝杆菌耐药性检测专家共识[J]. 中国防痨杂志, 2019, 41(2): 129-137., articleTitle=结核分枝杆菌耐药性检测专家共识, refAbstract=null)], funds=[Fund(id=1198318894696984639, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, awardId=2022-3-040, language=EN, fundingSource=Beijing Public Health Experts Project(2022-3-040), fundOrder=null, country=null), Fund(id=1198318895812669508, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, awardId=2022-3-040, language=CN, fundingSource=北京市高层次公共卫生技术人才项目(2022-3-040), fundOrder=null, country=null), Fund(id=1198318895930110027, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, awardId=KJ2023CX038, language=EN, fundingSource=Science and Technology Project of Tongzhou District of Beijing(KJ2023CX038), fundOrder=null, country=null), Fund(id=1198318896068522064, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, awardId=KJ2023CX038, language=CN, fundingSource=北京市通州区科技计划项目(KJ2023CX038), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1198318889009509274, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, xref=null, ext=[AuthorCompanyExt(id=1198318889017897883, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, companyId=1198318889009509274, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=Department of Clinical Laboratory, Beijing Chest Hospital of Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Institute, Beijing 101149, China), AuthorCompanyExt(id=1198318889034675100, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, companyId=1198318889009509274, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=北京市结核病胸部肿瘤研究所/首都医科大学附属北京胸科医院检验科,北京 101149)])], figs=[ArticleFig(id=1198318893417722865, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=EN, label=Fig.1, caption=Bilateral cross-resistance distribution of isolated strains from 71 cases of disseminated tuberculosis patients to RFP, Rfb, and Rft, figureFileSmall=OxGNlMW9q5+hfRRk4eKCGA==, figureFileBig=3oh9eCrMdvzduHmbtbaDKQ==, tableContent=null), ArticleFig(id=1198318893509997556, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=CN, label=图1, caption=71例血行播散性肺结核患者分离菌株对利福平、利福布汀和利福喷丁的双向交叉耐药性分布

RFP. 利福平;Rfb. 利福布汀;Rft. 利福喷丁

, figureFileSmall=OxGNlMW9q5+hfRRk4eKCGA==, figureFileBig=3oh9eCrMdvzduHmbtbaDKQ==, tableContent=null), ArticleFig(id=1198318893635826683, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=EN, label=Tab.1, caption=

Basic information and clinical characteristics of 71 patients with disseminated tuberculosis [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
项目 合计(n=71) 初治患者(n=48) 复治患者(n=23)
性别
51(71.8) 33(68.8) 18(78.3)
20(28.2) 15(31.2) 5(21.7)
年龄(岁)
10~19 5(7.0) 5(10.4) 0
20~29 10(14.1) 6(12.5) 4(17.4)
30~39 10(14.1) 8(16.7) 2(8.7)
40~49 9(12.7) 3(6.3) 6(26.1)
50~59 7(10.0) 3(6.3) 4(17.4)
60~69 13(18.3) 10(20.8) 3(13.0)
70~79 9(12.7) 6(12.5) 3(13.0)
80~89 8(11.2) 7(14.6) 1(4.3)
居住地
城镇 36(50.7) 27(56.3) 9(39.1)
农村 35(49.3) 21(43.8) 14(60.9)
基础疾病
低蛋白血症 44(62.0) 28(58.3) 16(69.6)
贫血 34(47.9) 21(43.8) 13(56.5)
高尿酸血症 28(39.4) 17(35.4) 11(47.8)
高血压 18(25.4) 13(27.1) 5(21.7)
糖尿病 11(15.5) 5(10.4) 6(26.1)
营养不良 9(12.7) 5(10.4) 4(17.4)
职业
农民 22(31.0) 12(25.0) 10(43.5)
退(离)休人员 20(28.2) 17(35.4) 3(13.0)
职员 8(11.3) 6(12.5) 2(8.7)
工人 6(8.5) 4(8.3) 2(8.7)
学生 6(8.5) 5(10.4) 1(4.3)
其他 9(12.7) 4(8.3) 5(21.7)
), ArticleFig(id=1198318893761655809, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=CN, label=表1, caption=

71例血行播散性肺结核患者的基本信息与临床特征[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
项目 合计(n=71) 初治患者(n=48) 复治患者(n=23)
性别
51(71.8) 33(68.8) 18(78.3)
20(28.2) 15(31.2) 5(21.7)
年龄(岁)
10~19 5(7.0) 5(10.4) 0
20~29 10(14.1) 6(12.5) 4(17.4)
30~39 10(14.1) 8(16.7) 2(8.7)
40~49 9(12.7) 3(6.3) 6(26.1)
50~59 7(10.0) 3(6.3) 4(17.4)
60~69 13(18.3) 10(20.8) 3(13.0)
70~79 9(12.7) 6(12.5) 3(13.0)
80~89 8(11.2) 7(14.6) 1(4.3)
居住地
城镇 36(50.7) 27(56.3) 9(39.1)
农村 35(49.3) 21(43.8) 14(60.9)
基础疾病
低蛋白血症 44(62.0) 28(58.3) 16(69.6)
贫血 34(47.9) 21(43.8) 13(56.5)
高尿酸血症 28(39.4) 17(35.4) 11(47.8)
高血压 18(25.4) 13(27.1) 5(21.7)
糖尿病 11(15.5) 5(10.4) 6(26.1)
营养不良 9(12.7) 5(10.4) 4(17.4)
职业
农民 22(31.0) 12(25.0) 10(43.5)
退(离)休人员 20(28.2) 17(35.4) 3(13.0)
职员 8(11.3) 6(12.5) 2(8.7)
工人 6(8.5) 4(8.3) 2(8.7)
学生 6(8.5) 5(10.4) 1(4.3)
其他 9(12.7) 4(8.3) 5(21.7)
), ArticleFig(id=1198318893841346563, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=EN, label=Tab.2, caption=

Distribution of 71 patients with disseminated tuberculosis by disease analysis [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
病情

合计

(n=71)

初治患者

(n=48)

复治患者

(n=23)

类型
急性血行播散性肺结核 58(81.7) 40(83.3) 18(78.3)
亚急性血行播散性肺结核 12(16.9) 7(14.6) 5(21.7)
慢性血行播散性肺结核 1(1.4) 1(2.1) 0
合并肺外结核情况
结核性脑膜炎 51(71.8) 30(62.5) 21(91.3)
脊椎结核 11(15.5) 8(16.7) 3(13.0)
淋巴结核 9(12.7) 4(8.3) 5(21.7)
关节结核 7(9.9) 3(6.3) 4(17.4)
肾结核 4(5.6) 3(6.3) 1(4.3)
肠结核 2(2.8) 1(2.1) 1(4.3)
盆腔结核 2(2.8) 1(2.1) 1(4.3)
脊髓结核 2(2.8) 2(4.2) 0
肝结核 1(1.4) 1(2.1) 0
膀胱结核 1(1.4) 1(6.3) 0
睾丸结核 1(1.4) 1(6.3) 0
心包炎 1(1.4) 0 1(4.3)
涉及2个及以上肺外部位 30(42.3) 18(37.5) 12(52.2)
涉及3个及以上肺外部位 12(16.9) 7(14.6) 5(21.7)
), ArticleFig(id=1198318893954592783, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=CN, label=表2, caption=

71例血行播散性肺结核患者病情分布[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
病情

合计

(n=71)

初治患者

(n=48)

复治患者

(n=23)

类型
急性血行播散性肺结核 58(81.7) 40(83.3) 18(78.3)
亚急性血行播散性肺结核 12(16.9) 7(14.6) 5(21.7)
慢性血行播散性肺结核 1(1.4) 1(2.1) 0
合并肺外结核情况
结核性脑膜炎 51(71.8) 30(62.5) 21(91.3)
脊椎结核 11(15.5) 8(16.7) 3(13.0)
淋巴结核 9(12.7) 4(8.3) 5(21.7)
关节结核 7(9.9) 3(6.3) 4(17.4)
肾结核 4(5.6) 3(6.3) 1(4.3)
肠结核 2(2.8) 1(2.1) 1(4.3)
盆腔结核 2(2.8) 1(2.1) 1(4.3)
脊髓结核 2(2.8) 2(4.2) 0
肝结核 1(1.4) 1(2.1) 0
膀胱结核 1(1.4) 1(6.3) 0
睾丸结核 1(1.4) 1(6.3) 0
心包炎 1(1.4) 0 1(4.3)
涉及2个及以上肺外部位 30(42.3) 18(37.5) 12(52.2)
涉及3个及以上肺外部位 12(16.9) 7(14.6) 5(21.7)
), ArticleFig(id=1198318894072033306, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=EN, label=Tab.3, caption=

Distribution of drug resistance types among 71 newly treated and retreated patients with disseminated tuberculosis [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
耐药类型

合计

(n=71)

初治患者

(n=48)

复治患者

(n=23)

χ2 P
单耐药 27(38.0) 15(31.3) 12(52.2) 2.889 0.089
链霉素 13(18.3) 5(10.4) 8(34.8) 4.650 0.031
异烟肼 13(18.3) 3(6.3) 10(43.5) 12.03 <0.001
利福喷丁 10(14.1) 2(4.2) 8(34.8) 9.647 0.002
对氨基水杨酸异烟肼 10(14.1) 4(8.3) 6(26.1) 2.716 0.099
利福平 9(12.7) 1(2.1) 8(34.8) 12.21 <0.001
利福布汀 9(12.7) 2(4.2) 7(30.4) 7.465 0.006
卷曲霉素 9(12.7) 6(12.5) 3(13.0) 0.100 0.752
左氧左旋氧氟沙星 8(11.3) 2(4.2) 6(26.1) 5.441 0.020
对氨基水杨酸 7(9.9) 3(6.3) 4(17.4) - 0.119
克拉霉素 5(7.0) 3(6.3) 2(8.7) - 0.656
氯法齐明 5(7.0) 2(4.2) 3(13.0) - 0.320
乙胺丁醇 3(4.2) 1(2.1) 2(8.7) - 0.244
乙硫异烟胺 3(4.2) 0 3(13.0) - 0.031
卡那霉素 2(2.8) 1(2.1) 1(4.3) - 0.546
阿米卡星 1(1.4) 0 1(4.3) - 0.324
莫西沙星 1(1.4) 0 1(4.3) - 0.324
), ArticleFig(id=1198318894160113696, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=CN, label=表3, caption=

71例初治和复治血行播散性肺结核患者任一耐药的分布情况[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
耐药类型

合计

(n=71)

初治患者

(n=48)

复治患者

(n=23)

χ2 P
单耐药 27(38.0) 15(31.3) 12(52.2) 2.889 0.089
链霉素 13(18.3) 5(10.4) 8(34.8) 4.650 0.031
异烟肼 13(18.3) 3(6.3) 10(43.5) 12.03 <0.001
利福喷丁 10(14.1) 2(4.2) 8(34.8) 9.647 0.002
对氨基水杨酸异烟肼 10(14.1) 4(8.3) 6(26.1) 2.716 0.099
利福平 9(12.7) 1(2.1) 8(34.8) 12.21 <0.001
利福布汀 9(12.7) 2(4.2) 7(30.4) 7.465 0.006
卷曲霉素 9(12.7) 6(12.5) 3(13.0) 0.100 0.752
左氧左旋氧氟沙星 8(11.3) 2(4.2) 6(26.1) 5.441 0.020
对氨基水杨酸 7(9.9) 3(6.3) 4(17.4) - 0.119
克拉霉素 5(7.0) 3(6.3) 2(8.7) - 0.656
氯法齐明 5(7.0) 2(4.2) 3(13.0) - 0.320
乙胺丁醇 3(4.2) 1(2.1) 2(8.7) - 0.244
乙硫异烟胺 3(4.2) 0 3(13.0) - 0.031
卡那霉素 2(2.8) 1(2.1) 1(4.3) - 0.546
阿米卡星 1(1.4) 0 1(4.3) - 0.324
莫西沙星 1(1.4) 0 1(4.3) - 0.324
), ArticleFig(id=1198318894264971299, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=EN, label=Tab.4, caption=

Distribution of different types of poly-drug resistance types in 71 newly treated and retreated patients with disseminated tuberculosis [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
耐药类型

合计

(n=71)

初治患者

(n=48)

复治患者

(n=23)

P
合计 5(7.0) 2(4.2) 3(13.0) 0.320
INH+Sm 2(2.8) 1(2.1) 1(4.3) 0.546
INH+Sm+EMB 1(1.4) 0 1(4.3) 0.324
INH+Rfb+Rft 1(1.4) 1(2.1) 0 1.000
Sm+RFP+Rfb+Rft 1(1.4) 0 1(4.3) 0.324
), ArticleFig(id=1198318894369828907, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=CN, label=表4, caption=

不同多耐药类型在71例血行播散性肺结核初治及复治患者中的分布情况[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
耐药类型

合计

(n=71)

初治患者

(n=48)

复治患者

(n=23)

P
合计 5(7.0) 2(4.2) 3(13.0) 0.320
INH+Sm 2(2.8) 1(2.1) 1(4.3) 0.546
INH+Sm+EMB 1(1.4) 0 1(4.3) 0.324
INH+Rfb+Rft 1(1.4) 1(2.1) 0 1.000
Sm+RFP+Rfb+Rft 1(1.4) 0 1(4.3) 0.324
), ArticleFig(id=1198318894466297905, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=EN, label=Tab.5, caption=

Distribution of different types of multidrug resistance in 71 newly treated and retreated patients with disseminated tuberculosis [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
耐药类型

合计

(n=71)

初治患者

(n=48)

复治患者

(n=23)

P
INH+RFP 8(11.3) 1(2.1) 7(30.4) 0.002
INH+RFP+Rft 1(1.4) 0 1(4.3) 0.324
INH+RFP+Rfb+Lfx+Rft+Mfx 1(1.4) 0 1(4.3) 0.324
INH+RFP+Sm+Rfb+Lfx+Rft+Pa 2(2.8) 0 2(8.7) 0.102
INH+RFP+Sm+Rfb+PAS+Lfx+Rft+Pa 1(1.4) 0 1(4.3) 0.324
INH+RFP+Sm+EMB+Rfb+Lfx+Rft+Pa 1(1.4) 1(2.1) 0 1.000
INH+RFP+Sm+Rfb+PAS+Lfx+Rft+Pto+Pa 1(1.4) 0 1(4.3) 0.324
INH+RFP+Sm+EMB+Rfb+Am+Cm+Lfx+Rft+Km+Pto+Clr+Pa+Cfz 1(1.4) 0 1(4.3) 0.324
), ArticleFig(id=1198318894550183988, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198196210768118359, language=CN, label=表5, caption=

不同耐多药类型在71例血行播散性肺结核初治复治患者中的分布情况[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
耐药类型

合计

(n=71)

初治患者

(n=48)

复治患者

(n=23)

P
INH+RFP 8(11.3) 1(2.1) 7(30.4) 0.002
INH+RFP+Rft 1(1.4) 0 1(4.3) 0.324
INH+RFP+Rfb+Lfx+Rft+Mfx 1(1.4) 0 1(4.3) 0.324
INH+RFP+Sm+Rfb+Lfx+Rft+Pa 2(2.8) 0 2(8.7) 0.102
INH+RFP+Sm+Rfb+PAS+Lfx+Rft+Pa 1(1.4) 0 1(4.3) 0.324
INH+RFP+Sm+EMB+Rfb+Lfx+Rft+Pa 1(1.4) 1(2.1) 0 1.000
INH+RFP+Sm+Rfb+PAS+Lfx+Rft+Pto+Pa 1(1.4) 0 1(4.3) 0.324
INH+RFP+Sm+EMB+Rfb+Am+Cm+Lfx+Rft+Km+Pto+Clr+Pa+Cfz 1(1.4) 0 1(4.3) 0.324
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血行播散性肺结核耐药情况分析(71例报告)
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施亦衡 , 王潮虹 , 杨斌 , 孙晴 , 晏君 , 龙嗣博 , 郑迈克 , 赵艳 , 王桂荣 *
解放军医学杂志 | 临床研究 2024,49(12): 1379-1385
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解放军医学杂志 | 临床研究 2024, 49(12): 1379-1385
血行播散性肺结核耐药情况分析(71例报告)
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施亦衡, 王潮虹, 杨斌, 孙晴, 晏君, 龙嗣博, 郑迈克, 赵艳, 王桂荣*
作者信息
  • 北京市结核病胸部肿瘤研究所/首都医科大学附属北京胸科医院检验科,北京 101149
  • 施亦衡,硕士研究生,主要从事结核病诊断新技术及相关机制的研究

通讯作者:

王桂荣,E-mail:
Analysis of drug resistance in disseminated pulmonary tuberculosis: 71 cases report
Yi-Heng Shi, Chao-Hong Wang, Bin Yang, Qing Sun, Jun Yan, Si-Bo Long, Mai-Ke Zheng, Yan Zhao, Gui-Rong Wang*
Affiliations
  • Department of Clinical Laboratory, Beijing Chest Hospital of Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Institute, Beijing 101149, China
出版时间: 2024-12-28 doi: 10.11855/j.issn.0577-7402.0338.2024.0731
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目的 分析血行播散性肺结核患者的耐药特点,为临床制定个体化治疗方案提供参考。方法 回顾性分析2015年1月-2024年1月首都医科大学附属北京胸科医院收治的71例血行播散性肺结核住院患者的临床资料。采用分枝杆菌微孔板药敏检测技术检测来自71例患者的结核分枝杆菌对16种抗结核药的敏感性,分析血行播散性肺结核患者的结核分枝杆菌培养结果、药敏试验结果、初治或复治情况、耐药情况,以及初治与复治患者耐药类型的差异。结果 71例血行播散性肺结核患者中,男51例(71.8%),急性血行播散性肺结核58例(81.7%),对16种抗结核药的总耐药率为38.0%。复治患者总耐药率与初治患者比较差异无统计学意义[52.2%(12/23) vs. 31.3%(15/48),P=0.089]。患者对16种抗结核药任一耐药的前7位为链霉素(Sm)、异烟肼(INH)各13例(18.3%),利福喷丁(Rft)、对氨基水杨酸异烟肼(Pa)各10例(14.1%),利福平(RFP)、利福布汀(Rfb)、卷曲霉素(Cm)各9例(12.7%);初治患者任一耐药的前6位为Cm 6例(12.5%),Sm 5例(10.4%),Pa 4例(8.3%),INH、克拉霉素(Clr)、对氨基水杨酸(PAS)各3例(6.3%);复治患者任一耐药的前7位为INH 10例(43.5%),Sm、RFP、Rft各8例(34.8%),Rfb 7例(30.4%),Pa、左氧左旋氧氟沙星(Lfx)各6例(26.1%)。患者对16种抗结核药的总单耐药率、总多耐药率、总耐多药率分别为9.9%、7.0%、11.3%;所有单耐药患者均为初治患者;复治患者多耐药率与初治患者比较差异无统计学意义[13.0% vs. 4.2%,P=0.591],但耐多药率明显高于初治患者[30.4% vs. 2.1%,P=0.002]。结论 血行播散性肺结核耐药情况严峻,临床医师可根据药敏试验结果制定个性化的抗结核治疗方案。

血行播散性肺结核  /  药物敏感性试验  /  耐药性  /  耐多药

Objective To analyze the characteristics of drug resistance in patients with disseminated pulmonary tuberculosis, and provide references for the clinical development of individualized treatment plans. Methods A retrospective analysis was conducted on 71 hospitalized patients with disseminated pulmonary tuberculosis treated at the Beijing Chest Hospital, Capital Medical University from January 2015 to January 2024. The susceptibility of Mycobacterium tuberculosis from these patients to 16 anti-tuberculosis drugs was detected using the microplate method for mycobacterial drug susceptibility testing. The study analyzed the culture results of Mycobacterium tuberculosis, drug susceptibility test results, initial treatment or re-treatment status, drug resistance, and differences in drug resistance types between initial and re-treated patients. Results Among the 71 patients with disseminated pulmonary tuberculosis, there were 51 males (71.8%), and 58 cases (81.7%) of acute disseminated pulmonary tuberculosis, with an overall drug resistance rate to 16 anti-tuberculosis drugs of 38.0%. There was no statistically significant difference in the total drug resistance rate between re-treated patients and those undergoing initial treatment [52.2%(12/23) vs. 31.3%(15/48), P=0.089]. The top 7 drugs to which patients were resistant were streptomycin (Sm) and isoniazid (INH) with 13 cases each (18.3%), rifapentine (Rft) and isoniazid aminosalicylate (Pa) with 10 cases each (14.1%), rifampicin (RFP), rifabutin (Rfb), and capreomycin (Cm) with 9 cases each (12.7%). The top 6 drugs to which initially treated patients were resistant were Cm with 6 cases (12.5%), Sm with 5 cases (10.4%), Pa with 4 cases (8.3%), INH, clarithromycin (Clr), and p-aminosalicylic acid (PAS) with 3 cases each (6.3%). The top 7 drugs to which re-treated patients were resistant were INH with 10 cases (43.5%), Sm, RFP, and Rft with 8 cases each (34.8%), Rfb with 7 cases (30.4%), Pa and levofloxacin (Lfx) with 6 cases each (26.1%). The overall mono-resistance rate, poly-drug resistance rate, and multidrug-resistant rate to 16 anti-tuberculosis drugs were 9.9%, 7.0%, and 11.3%, respectively; all mono-resistance patients were initially treated; there was no statistically significant difference in the poly-drug resistance rate between re-treated and initially treated patients (13.0% vs. 4.2%, P=0.591), but the multidrug-resistant rate was significantly higher in re-treated patients (30.4% vs. 2.1%, P=0.002). Conclusion Drug resistance in disseminated pulmonary tuberculosis is severe. Clinical physicians can develop personalized anti-tuberculosis treatment plans based on drug susceptibility test results.

disseminated pulmonary tuberculosis  /  antimicrobial susceptibility test  /  drug resistance  /  multi-drug resistance
施亦衡, 王潮虹, 杨斌, 孙晴, 晏君, 龙嗣博, 郑迈克, 赵艳, 王桂荣. 血行播散性肺结核耐药情况分析(71例报告). 解放军医学杂志, 2024 , 49 (12) : 1379 -1385 . DOI: 10.11855/j.issn.0577-7402.0338.2024.0731
Yi-Heng Shi, Chao-Hong Wang, Bin Yang, Qing Sun, Jun Yan, Si-Bo Long, Mai-Ke Zheng, Yan Zhao, Gui-Rong Wang. Analysis of drug resistance in disseminated pulmonary tuberculosis: 71 cases report[J]. Medical Journal of Chinese People’s Liberation Army, 2024 , 49 (12) : 1379 -1385 . DOI: 10.11855/j.issn.0577-7402.0338.2024.0731
结核病是危害严重的慢性传染病,世界卫生组织(WHO)的数据显示,2022年全球新发结核病患者1060万例,其中我国新增结核病患者74.8万例,仅次于印度和印度尼西亚,居全球第3位[1]。血行播散性肺结核又称粟粒性肺结核,是结核分枝杆菌经由病灶通过血液传播引起的结核病变[2];该病发病迅速、并发症多、症状严重,可发生在各个年龄段[3];根据影像学和临床特征,可分为急性、亚急性和慢性[4-9]。血行播散性肺结核属于危重结核病,血液传播的结核分枝杆菌常导致其他部位器官结核病变,使治疗难度大幅度增加,且耐药血行播散性肺结核药物治疗效果不佳,预后较差。鉴于此,本研究对71例血行播散性肺结核患者的临床信息与耐药特征进行回顾性分析,旨在为临床治疗方案的制订提供数据支持,以进一步提高治疗效果。
通过首都医科大学附属北京胸科医院电子病例管理系统,收集2015年1月-2024年1月该院收治的71例血行播散性肺结核住院患者的临床资料进行回顾性分析。纳入标准:(1)符合2017年《肺结核诊断标准》(WS288-2017)中血行播散性肺结核的胸部影像学特征,患者痰液、组织或其他体液标本经分枝杆菌培养和菌种鉴定为结核分枝杆菌;(2)分离获得的结核分枝杆菌进行了16种抗结核药物敏感性试验。排除标准:治疗过程记录和药物敏感性试验结果不完整。本研究经首都医科大学附属北京胸科医院论理委员会审核批准(LW-2024-029号)。
收集患者的性别、年龄、职业、病史、药物敏感性试验结果等相关资料。
按照《结核病诊断实验室检验规程》推荐的方法,采用改良罗氏或MGIT960培养法培养痰液、血液、组织或其他体液标本。
对于在含对硝基苯甲酸培养基上不生长、初步鉴定为结核分枝杆菌复合群的菌株,参照文献[10-12]的方法联合测定16S rRNA、rpoB、16S~23S rRNA间隔区(internally transcribed spacer,ITS)和hsp65基因序列,基因测序结果在NCBI网站(http://www.ncbi.nlm.nih.gov)上进行Blast比对,确定菌种类型。
应用分枝杆菌微孔板药敏检测试剂盒(培养法;珠海银科医学工程股份有限公司)测定结核分枝杆菌对异烟肼(INH)、利福平(RFP)、乙胺丁醇(EMB)、链霉素(Sm)、利福喷丁(Rft)、利福布汀(Rfb)、左氧左旋氧氟沙星(Lfx)、莫西沙星(Mfx)、卡那霉素(Km)、阿米卡星(Am)、卷曲霉素(Cm)、丙硫异烟胺(Pto)、对氨基水杨酸(PAS)、对氨基水杨酸异烟肼(Pa)、克拉霉素(Clr)和氯法齐明(Cfz)共16种抗结核药物的敏感性。
(1)总耐药率,指在所有患者中,对任一抗结核药物产生耐药性的患者所占比例;任一药物耐药是指体外药敏试验结果显示结核分枝杆菌对上述16种抗结核药物中至少一种药物耐药。(2)单耐药,参照《耐药结核病化学治疗指南(2019年简版)》[13],指体外药敏试验结果显示结核分枝杆菌仅对一种一线抗结核药耐药。(3)多耐药,指体外药敏试验结果显示结核分枝杆菌对两种或更多一线抗结核药耐药,但不包括同时对RFP和INH耐药。(4)耐多药,指体外药敏试验结果显示结核分枝杆菌至少同时对RFP和INH耐药。(5)双向交叉耐药,指体外药敏试验结果显示结核分枝杆菌对一种抗结核药耐药,且对另一种结构近似或作用性质相同的抗结核药耐药。(6)初治患者,指从未因结核病接受过抗结核药治疗,或使用抗结核药治疗时间<1个月。(7)复治患者,指既往不规律使用抗结核药治疗≥1个月以及初治失败和复发者[14]
分析血行播散性肺结核患者的结核分枝杆菌培养结果、药敏试验结果、初治或复治情况、耐药情况,以及初治与复治患者的耐药类型差异。
采用SPSS 24.0软件和Prism 10.1.2软件进行统计分析。计数资料以例(%)表示,初治、复治患者耐药率的比较采用χ2检验、校正χ2检验或Fisher精确概率检验。P<0.05为差异有统计学意义。
共纳入结核分枝杆菌培养阳性且具有表型药敏试验结果的血行播散性肺结核患者71例,其中初治患者48例(67.6%),复治患者23例(32.4%);男51例(71.8%),女20例(28.2%),男女比例为2.55:1;年龄13~87岁,中位年龄44岁;患者居住地为城镇与农村者比例相近[36例(50.7%) vs. 35例(49.3%)];职业以农民(22例,31.0%)和退(离)休人员(20例,28.2%)居多。初治与复治患者的基本信息及临床特征比较,差异均无统计学意义(P>0.05)(表1)。
71例中,急性血行播散性肺结核58例(81.7%),慢性血行播散性肺结核仅1例(1.4%)。合并的肺外结核中,结核性脑膜炎51例(71.8%),脊椎结核11例(15.5%);涉及两个及以上肺外部位感染者30例(72.3%),涉及3个及以上肺外部位感染者12例(16.9%)(表2)。
71例血行播散性肺结核患者分离菌株的总耐药率为38.0%(27/71);复治患者的总耐药率与初治患者比较差异无统计学意义[52.2%(12/23)vs. 31.3%(15/48),P=0.089](表3)。
71例血行播散性肺结核患者分离菌株中对16种抗结核药任一药物耐药顺位前7位为Sm 13例(18.3%),INH 13例(18.3%),Rft 10例(14.1%),Pa 10例(14.1%),RFP 9例(12.7%),Rfb 9例(12.7%),Cm 9例(12.7%)。初治患者任一耐药顺位前6位为Cm 6例(12.5%),Sm 5例(10.4%),Pa 4例(8.3%),INH 3例(6.3%),Clr 3例(6.3%),PAS 3例(6.3%);复治患者任一耐药顺位前7位为INH 10例(43.5%),Sm 8例(34.8%),RFP 8例(34.8%),Rft 8例(34.8%),Rfb 7例(30.4%),Pa 6例(26.1%),Lfx 6例(26.1%)(表3)。
71例血行播散性肺结核患者分离菌株中仅对一种抗结核药耐药者共7株,总单耐药率为9.9%(7/71),所有单耐药均为初治患者。
71例血行播散性肺结核患者分离菌株中多耐药菌株共5株,多耐药率为7.0%(5/71);复治患者的多耐药率与初治患者比较差异无统计学意义[13.0%(3/23) vs. 4.2%(2/48),P=0.591,表4]。
71例血行播散性肺结核患者分离菌株中同时对INH和RFP耐药的菌株有8株,总耐多药率为11.3%(8/71);复治患者的耐多药率明显高于初治患者[30.4%(7/23) vs. 2.1%(1/48),P=0.002,表5]。
71例血行播散性肺结核患者分离菌株中,Rft和Rfb在RFP耐药株中的耐药率分别为100%(9/9)、88.9%(8/9);RFP和Rft在Rfb耐药株中的耐药率分别为88.9%(8/9)、100%(9/9);RFP和Rfb在Rft耐药株中的耐药率同为90%(9/10)(图1)。
23例复治血行播散性肺结核患者中,初治时有17例为敏感,6例为耐药。在17例敏感患者中,10例(58.8%)接受了规范的HRZE抗结核治疗方案,5例(29.4%)采用HRZE联用氟喹诺酮类抗结核药物。初治采用规范HRZE抗结核治疗的患者中,本次药敏试验结果显示50%(5/10)的患者对一线抗结核药物中至少一种耐药;采用HRZE联用氟喹诺酮类药物的复治患者中,本次药敏试验结果显示40%(2/5)对一线抗结核药物中至少一种耐药,没有患者对氟喹诺酮类抗结核药耐药。
血行播散性肺结核是一种致命性的结核病变,源于结核分枝杆菌病灶,并通过淋巴和血液系统大规模扩散[15];与浸润性肺结核相比,血行播散性肺结核的临床症状更严重,对肝肾功能损害更大[16]。艾滋病的传播、免疫抑制剂使用的增多、部分手术如体外受精胚胎移植(IVF-ET)的开展等[17-18],可能会使血行播散性肺结核的发生风险进一步增高。该病临床症状不典型,易因误诊而给予错误的抗结核药物治疗[16],导致患者的死亡风险增高。为了提高血行播散性耐药患者的治疗成功率,需要系统记录耐药结核病患者的用药方案,及时进行结核分枝杆菌耐药敏感试验,针对不同肺外合并结核部位选择合适的治疗措施[19-20]
本研究中,耐药血行播散性肺结核患者在各年龄段分布较均匀;职业以农民(31.0%)和退(离)休人员(28.2%)居多。究其原因,可能与退(离)休人员年龄偏大、内脏功能衰减、治疗依从性较低、抗结核药不良反应发生率较高,农民工作、生活环境中的感染风险相对较高等相关[21];在71例血行播散性肺结核患者中,低蛋白血症、贫血、高尿酸血症、高血压、糖尿病和营养不良等基础疾病分别占62.0%、47.9%、39.4%、25.4%、15.5%和12.7%;上述基础疾病多与结核病的发生密切相关[22-26],可能使患者免疫功能受损,增高了罹患结核病的概率,进一步造成难治疗、易复发、高风险的现象。由于基础疾病的存在,使得治疗复杂且具有挑战性。因此,及时进行耐药检测能够为临床医师制订用药方案时指明方向,提高治愈率[27]
本研究患者主要表现为急性血行播散性肺结核(81.7%)。由于结核分枝杆菌通过血液传播,患者的肺外脏器受到侵害,容易引起严重的并发症[20,28]。在本研究中,患者合并肺外结核的范围较广,其中结核性脑膜炎占比最高(71.8%),与国内其他研究结果相近;在血行播散性肺结核患者中,结核性脑膜炎是各型颅内结核中的常见类型,且其病死率和致残率较高,可能与颅内血流丰富、血氧饱和度高等因素相关[29-30]。本研究结果提示,临床医师在治疗血行播散性肺结核时,应高度重视是否存在合并颅内结核的情况;对于出现类似症状的患者,应及时进行CT等检查以评估颅内损害程度。此外,若患者被诊断为耐药性结核病,其所需治疗周期将更长,死亡风险更高。对于合并严重并发症的血行播散性肺结核患者,通过耐药敏感性检测以选择有效的药物治疗方案可缩短用药时间,有利于遏制疾病的恶化。
本研究血行播散性肺结核患者分离菌株的总耐药率为38.0%,总多耐药率为7.0%,总耐多药率为11.3%,其中复治患者总耐多药率明显高于初治患者。与2018年全国结核病耐药检测数据[31]相比,本研究中复治患者的多耐药率和耐多药率均较高(13.0% vs. 5.06%,30.4% vs. 18.0%),表明复治血行播散性肺结核患者的耐药情况较为严重。此外,在所有抗结核药中,71例患者对Sm和INH的耐药率最高(均为18.3%),这与德阳市[32]、广东省[33]的耐药结核病统计结果相似。虽然链霉素近年来在临床已很少使用,但2007年全国耐药基线调查结果显示,我国初治结核病患者的链霉素耐药率达27.7%,复治患者达37.2%[34],提示链霉素耐药结核分枝杆菌已在我国广泛分布。在一线抗结核药物中,Rft、Rfb和RFP同属于利福霉素家族,存在双向交叉耐药性[13]。有研究报道,RFP和Rft为完全交叉耐药,RFP和Rfb为非完全交叉耐药[35];本研究中Rft在RFP耐药株中的耐药率为100%,Rfb在RFP耐药株中的耐药率为88.9%,约有11.1%的RFP耐药株对Rfb敏感,此结果低于文献中描述的概率(11.1% vs. 31.0%)。在氟喹诺酮类抗结核药中,Lfx的耐药率明显高于Mfx(11.3% vs. 1.4%);在二线氨基糖苷类和多肽类抗结核药中,Cm的耐药率明显高于Am(12.7% vs. 1.4%)和Km(12.7% vs. 2.8%);基于上述结果,对于耐药血行播散性肺结核,临床医师在对同一类别的抗结核药进行选择时,可优先选择Mfx、Am、Cm。
根据《中国结核病防治工作技术指南》,血行播散性肺结核的推荐治疗方案为前2个月采用HRZE(异烟肼、利福平、吡嗪酰胺和乙胺丁醇)的强化治疗[36]。本研究中,17例初治时耐药检测敏感的复治血行播散性肺结核患者中,接受了规范的HRZE抗结核治疗的10例中5例(50.0%)对至少一种一线抗结核药耐药,且在一线抗结核药中,EMB与RFP耐药率、INH与Sm耐药率差异均无统计学意义;另外7例初治时接受了非规范化治疗方案的患者中,仅1例(14.3%)对至少一种一线抗结核药物耐药,其耐药性低于初治接受规范化治疗队列,但差异尚无统计学意义。提示临床医师对确诊的血行播散性肺结核患者,需要依据除耐药性检测外的其他诊断技术,以及观察患者对当前治疗方案的反应进行综合判断,制订个性化的治疗计划。2023年WHO全球结核病年报显示,2022年全球耐多药/利福平耐药结核病患者有41万例(3.9%);我国耐药患者为3.0万例;尽管耐药结核病总体治愈成功率有所提升,但仍然存在治愈难度较大、难以精确防控等问题[1,37-38]。药物敏感性试验可识别耐药菌株的存在,有利于控制耐药性结核病传播,还能帮助监测耐药性的发展趋势和变化,其中传统的表型药物敏感性试验(drug susceptibility testing,DST)被认为是目前耐药性检测的“金标准”,但由于其培养周期长、易污染及医保时间限制等因素[39],本研究中许多患者在住院期间无法获得微孔板药敏试验结果报告。考虑到血行播散性肺结核发展过程的复杂性,相较于分子DST检测,传统表型DST检测方法可为临床医师提供更直观的药敏结果。
综上所述,血行播散性肺结核是一种严重的全身性结核病,常合并多脏器病变。在临床实践中,临床医师应根据药物敏感性试验结果及时调整治疗方案,尽早开始个性化的抗结核治疗,长期监测并发症,以利于患者的康复。本研究存在一定局限性:由于血行播散性肺结核的发病率较低,本研究样本量较小,且患者来源于单中心,因此整体人群的代表性较弱;此外,血行播散性肺结核耐药性的相关研究和文献数量较少,参考信息有限。鉴于此,未来的研究可致力于扩大样本规模,开展多中心合作,以增加研究的代表性和结果的可靠性。
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2024年第49卷第12期
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doi: 10.11855/j.issn.0577-7402.0338.2024.0731
  • 接收时间:2024-03-16
  • 首发时间:2025-11-20
  • 出版时间:2024-12-28
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  • 收稿日期:2024-03-16
  • 录用日期:2024-04-28
基金
Beijing Public Health Experts Project(2022-3-040)
北京市高层次公共卫生技术人才项目(2022-3-040)
Science and Technology Project of Tongzhou District of Beijing(KJ2023CX038)
北京市通州区科技计划项目(KJ2023CX038)
作者信息
    北京市结核病胸部肿瘤研究所/首都医科大学附属北京胸科医院检验科,北京 101149

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2种不同金属材料的力学参数

Family
属数
Number of
genus
种数
Number of
species
占总种数比例
Percentage of
total species (%)

Genus
种数
Number of
species
占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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