快速生长分枝杆菌肺病21例的疗效分析

The treatment outcomes of 21 cases of rapidly growing mycobacteria related pulmonary disease

目的探讨以克拉霉素和阿米卡星为主要药物的治疗方案对致病性快速生长分枝杆菌（RGM）肺病的疗效。方法回顾性分析2008年1月至2011年10月在广州市胸科医院就诊的21例RGM肺病患者的临床疗效。治疗药物以阿奇霉素0．5g,／d或克拉霉素0．5-1．0g／d、阿米卡星0．4-0．6g／d为主，并根据患者的用药史及药敏试验结果制定个体化治疗方案。观察患者治疗6个月的症状改善、影像学和痰菌变化及不良反应。结果21例RGM肺病患者对阿米卡星和克拉霉素耐药例数分别为9例和5例，少于其他抗结核药物。病灶范围〉3个肺野17例，咳嗽、咳痰21例，痰中带血18例，胸闷、气促15例，发热15例。治疗2周时，21例体温恢复正常，气促症状改善，12例咳嗽、咳痰症状减轻，16例痰中带血症状减轻；治疗6个月时，21例中病灶吸收12例，空洞缩小9例，痰菌转阴8例。对克拉霉素敏感的16例中有11例痰涂片阴性，对阿米卡星敏感的12例中有11例痰涂片阴性。常见不良反应为胃肠道反应、血液系统和肝功能损害等。结论RGM肺病患者对阿米卡星和克拉霉素的耐药率较低，但以阿米卡星和克拉霉素为主的个体化治疗方案临床疗效并不满意，应寻找新的敏感药物组合成有效的治疗方案。

Objective To explore the efficacy of the chemotherapeutic regimen with clarithromycin （CTM） and amikacin （AMK） as the main drugs in the therapy of rapidly growing mycobacteria （ RGM ） related pulmonary disease. Methods The clinical efficacy of 21 patients with RGM related pulmonary disease was retrospectively analyzed from January 2008 to October 2011 in Guangzhou Chest Hospital. The individual chemotherapeutic regimen was mainly based on azithromycin （ATM） 0. 5 g/d or CTM 0. 5 - 1.0 g/d, AMK 0. 4 - 0. 6 g/d according to the medication history and antimicrobial susceptibility tests. After 6 months of treatment, symptomatic improvement, changes of imaging findings, sputum cultures and adverse effects were observed. Results In the 21 cases of RGM related pulmonary disease, drug resistance to amikacin （9 cases） and clarithromycin （5 cases） were relatively low as compared to other antituberculous drugs. Lesions involving more than 3 lung fields were seen in 17 cases, cough and phlegm in 21, bloody sputum in 18, chest pain and shortness of breath in 15, and fever in 15 cases. After 2-week treatment, fever disappeared and shortness of breath improved in all the cases. Cough and phlegm improved in 12 and bloody sputum improved in 16 cases. After 6-month treatment, lesion absorption occurred in 12 cases, lung cavity became smaller in 9 cases and sputum culture became negative in 8 cases. Of the 16 eases sensitive to CTM, 11 was smear-negative, and of the 12 cases sensitive to AMK, 11 was smear-negative. Common adverse effects included gastrointestinal symptoms, liver damage and blood abnormalities. Conclusions Patients with RGM related pulmonary disease had low rates of drug resistance to CTM and AMK. However, individual chemotherapy regimen based on CTM and AMK showed unsatisfactory clinical efficacy. More sensitive drugs combined with potent chemotherapy regimen are needed for the treatment of this disease.