128例脊柱结核耐药患者的临床分析

Clinical analysis on drug-resistant tuberculosis in 128 patients with spinal tuberculosis

目的分析脊柱结核病灶中结核分枝杆菌菌型,耐药性及耐药原因和处理原则。方法搜集首都医科大学附属北京胸科医院2005年1月至2012年1月确诊为脊柱结核的住院患者1057例。通过穿刺或外科手术获得骨病灶中的脓液及干酪样物,进行结核分枝杆菌培养和药敏试验。结果在1057例患者中,分枝杆菌培养阳性128例,阳性率12.1%;128例患者中耐一线药物异烟肼、利福平及链霉素最多,分别为22例、16例、27例,占17.2%,12.5%及21.1%;利福平、利福喷丁及链霉素的高浓度耐药情况严重,分别为16例、12例、25例,占耐该药菌株中的100.0%(16/16),75.0%(12/16),92.6%(25/27);其中耐多药结核(MDR-TB)21例,占阳性患者的16.4%(21/128),均为复治患者,培养阳性患者均按照药敏试验结果给予规范的抗结核治疗或个性化治疗,同时择期给予手术治疗,均痊愈。结论脊柱结核病灶中结核分枝杆菌耐药仍以常规药物(异烟肼、利福平、链霉素、利福喷丁)为主,耐多药脊柱结核多为复治患者,即以获得性耐药为主。因此早期获得患者耐药及药敏,并给予合理的抗结核治疗并结合合理的手术方法是治愈结核病的关键,对防止耐多药发生有重要意义。

Objective To analyze the drug-resistance, cause of drug-resistance and principle of management. Methods 1057 patients admitted and diagnosed definitely as spinal tuberculosis in our hospital from Jan. 2005 to Jan. 2012 were enrolled. The samples of pus and caseous matter collected by puncture or operation were culture and drug susceptible testing（DST）. Results Of 1057 cases, 128 cases were culture positive（128/1057,12.1%）. Among 128 patients with drug-resistance tuberculosis, the cases of drug-resistant to isoniazid, rifampicin and streptomycin were 22, 16 and 27, respectively. The rates of drug-resistance were 17.2%, 12.5%and 21.1%, respectively. High concentration drug-resistance was serious and common in rifampicin, rifapentine and streptomycin which accounted for 100.0%（16/16）, 75.0%（12/16） and 92.6%（25/27） among drug-resistant strains. The rate of cases with multi-drug resistant tuberculosis（MDR-TB） which all belonged to retreatment were 16.4%（21/128）. All patients were given standardized or individual treatment plus selective operation according to the result of DST. All patients were cured. Conclusion Mycobacterium tuberculosis from focus of spinal tuberculosis was mainly resistant to first-line drugs such as isoniazid, rifampicin, rifapentine and streptomycin. All patients with MDR-TB were retreatment and were mainly secondary tuberculosis. It is key step for efficacy that rational treatment according to DST result earlier is performed. It is also useful to prevent MDR-TB.