耐氟喹诺酮类药物的耐多药结核病患者预后影响因素分析

朱翠云; 孙峰; 张文宏; 卢洪洲

doi:10.12025/j.issn.1008-6358.2017.20170371

摘要: 目的：调查耐氟喹诺酮类药物的耐多药结核病(multidrug-resistant tuberculosis，MDR-TB)患者的治疗预后，以指导临床治疗方案的制定和监测。方法：入组的99例MDR-TB患者中，属氟喹诺酮耐药株引起的71例，属氟喹诺酮敏感株引起的28例，对MDR-TB患者的临床治疗效果进行回顾性研究。所有MDR-TB患者均采取个体化治疗方案，随访时间为24个月。统计分析患者的临床疗效、痰涂片、痰培养检查结果和临床结局，使用logistic回归法分析疗效影响因素。结果：MDR-TB患者的总体治愈率为51.5%，个体化治疗完成后仍有8.5%的患者复发。MDR-TB患者接受个体化治疗12个月后，痰检阳性者治疗失败率为93.5%，治愈率6.5%；而痰检阴性者的治愈率为90.6%，治疗失败率9.4%。单因素logistic回顾分析显示：MDR-TB治疗失败的危险因素包括患者年龄大于40岁(P=0.034)、氟喹诺酮耐药(P<0.001)和不含氟喹诺酮方案(P=0.031)。多因素logistic回归分析显示：MDR-TB治疗失败的危险因素为氟喹诺酮耐药(P=0.001，OR值为7.06)，治疗方案含氟喹诺酮是保护因素(P=0.025，OR值为0.40)。结论：MDR-TB的总体治愈率不理想，个体化治疗完成后治愈患者仍有较高复发风险；MDR-TB患者接受个体化治疗12个月的痰检结果对预后有很高的预测价值，该时间点可能是调整治疗方案的重要时机；氟喹诺酮耐药是MDR-TB治疗失败的独立危险因素，而治疗方案中加用氟喹诺酮是MDR-TB治疗成功的关键因素。

Abstract: Objective：To investigate the prognosis of fluoroquinolone-resistant multidrug-resistant tuberculosis (MDR-TB) patients so as to guide the development and monitoring of clinical treatment plans. Methods：Of the 99 MDR-TB patients, 71 were caused by fluoroquinolone-resistant strains, and 28 were caused by fluoroquinolone-sensitive strains. The clinical treatment effects of MDR-TB patients were retrospectively studied. All MDR-TB patients were treated with individualized plans and followed up for 24 months. The clinical efficacy, sputum smear, sputum culture test results and clinical outcomes were statistically analyzed, and the influencing factors were analyzed by logistic regression analysis. Results： The overall cure rate of MDR-TB patients was 51.5%, and the disease relapsed in 8.5% of the patients after individualized treatment was completed. After 12 months of individualized treatment for MDR-TB patients, the failure rate of sputum smear positive patients was 93.5%, the cure rate was only 6.5%, while the cure rate of sputum negative patients was 90.6%, and the failure rate was only 9.4%. Single factor logistic regression analysis showed that the risk factors for MDR-TB treatment included the age of patients older than 40 years (P=0.034), fluoroquinolone resistance (P<0.001) and fluoroquinolone-free program (P=0.031). Multivariate logistic regression analysis showed that the risk factor for MDR-TB treatment was fluoroquinolone resistance (P=0.001, OR=7.06), and fluoroquinolone treatment was a protective factor (P=0.025, OR=0.33). Conclusions：The overall cure rate of MDR-TB infection is not ideal. The cured patients who accepted and completed individualized treatment still have a high risk of recurrence. The results of sputum examination after 12 months of individualized treatment in patients with MDR-TB have a high predictive value for prognosis, and this time point may be an important opportunity to adjust the treatment plan. Fluoroquinolone resistance is an independent risk factor for the failure of MDR-TB infection, while fluoroquinolone-included plan is the key factor for the success of MDR-TB treatment.