人类免疫缺陷病毒感染合并结核病患者死亡相关因素分析

Factors related to in-hospital deaths in patients co-infected with human immunodeficiency virus and tuberculosis

目的 回顾性调查HIV合并结核病（TB）双重感染（HIV-TB）死亡病例的临床特征,探索导致HIV-TB双重感染病例死亡的相关危险因素.方法 收集2004年11月至2009年5月在上海市公共卫生临床中心住院期间死亡的53例HIV-TB双重感染患者（死亡组）,同时选择同期住院期间存活的79例HIV-TB双重感染患者（存活组）,对两组的人口学资料、临床特点、放射学特征和实验室检查进行对照研究.采用多因素Logistic逐步回归分析,探索与HIV-TB双重感染患者死亡相关的危险因素.结果 HIV-TB双重感染病例共459例,死亡53例,病死率为11.5%,入院1周内死亡25例,占47.2%,死于肺结核34例,占64.2%.死亡组患者中体质量≤50 kg者较存活组多见（χ^2=7.50）,痰标本抗酸杆菌涂片阳性率和结核菌培养阳性率（χ^2=4.04、14.27）,耐药结核病（χ^2=9.00）,耐多药结核病（χ^2=6.39）,肺外结核发生率（χ^2=6.99）,复治结核病（χ^2=5.92）,抗结核治疗不规范（χ^2=12.07）,肺部病灶广泛者（病灶＞50%肺野,χ^2=20.21）,合并真菌感染、呼吸衰竭、肺外脏器功能受损者（χ^2=3.46、4.27、3.46）,HIV感染＞5年（χ^2=7.19）、高效抗反转录病毒疗法（HAART）不规范（χ^2=5.16）;CD4^＋T淋巴细胞计数≤200×10^6/L者（x=12.99）均高于存活组（均P＜0.05＝.多因素Logistic逐步回归分析显示,抗结核治疗不规范、肺部病灶广泛、耐多药结核病和CD4＋T淋巴细胞计数≤200×10^6/L是HIV-TB主要的死亡相关危险因素.结论 HIV-TB双重感染死亡病例病情呈现复杂性、多样性,抗结核治疗不规范、肺部病灶广泛、耐多药结核病和CD4＋T淋巴细胞计数≤200×10^6/L是导致HIV-TB双重感染患者死亡主要的相关危险因素.

Objective To evaluate the risk factors associated with in-hospital death in patients co-infected with human immunodeficiency virus and Mycobacterium tuberculosis （HIV-TB）. Methods A retrospective case-control study was performed in patients admitted to Shanghai Public Health Clinical Center from November 2004 to May 2009. Fifty-three HIV-TB patients who died during hospitalization were matched with 79 HIV-TB co-infected patients who survived during hospitalization.Clinical, demographic, and radiological characteristics of the two groups were compared by the retrospective case-control study method. Multivariate Logistic stepwise regression analysis was performed to explore the risk factors contributing to death in HIV-TB co-infected patients. Results Among the 459 co-infected patients, 53 （11.5%） cases died during hospitalization and 25 cases died during the first week in hospital. Sixty-four point two percent dead patients （34/53） died from tuberculosis. Several factors were associated with worse prognosis in the death group compared to the survival group, which included body weight≤50 kg （χ^2= 7.50）, positive for acid-fast bacilli in sputum smear or culture exam （χ^2 4. 04, 14. 27）, drug-resistant/multi-drug resistant Mycobacterium tuberculosis infection （χ^2=9.00,6.39）, extra-pulmonary tuberculosis infection （χ^2=6.99）, retreated tuberculosis （χ^2= 5. 92）, non-standardized anti-tuberculosis treatment （χ^2= 12. 07）, extensive pulmonary TB infection （lesions ≥50% of lung fields, χ^2= 20. 21）, co-infection with fungi （χ^2=3.46）, respiratory failure （χ^2= 4.27）, non-pulmonary organ impairment （χ^2= 3.46）, HIV infection longer than 5 years （χ^2= 7. 19）, non-standardized highly active antiretroviral therary treatment （χ^2 =5.16） and CD4＋ T lymphocyte count ≤ 200 × 10^6/L （χ^2= 12.99） （all P〈0. 05）. Multivariate Logistic regression analysis showed that non-standardized anti-TB treatment, extensive pulmonary TB infection, multi-drug resistant TB infection and CD4^＋ T lymphocyte count ≤ 200 × 10^6/L were the major risk factors related to in-hospital mortality. Conclusions Non-standardized anti-TB treatment,extensive pulmonary TB infection, multi-drug resistant TB infection and CD4＋ T lymphocyte count ≤200 × 10^6/L are the major risk factors related to in-hospital mortality in the patients co-infected with TB and HIV.