耐多药肺结核患者发现策略分析

Analysis of case finding strategy of multidrug-resistant pulmonary tuberculosis patients

目的 探索并完善耐多药肺结核患者的发现策略.方法 根据不同的地理和经济条件选取天津、重庆万州、河南濮阳、浙江衢州、黑龙江大庆这5个地区作为研究地区.涂阳肺结核患者的标本天津、大庆和濮阳地区运输至地市级实验室进行痰培养和药物敏感性试验（简称“地市级同时完成培养及药敏试验模式”,模式1）,衢州和重庆6县（区）则由县（区）级疾病预防控制中心（结核病防治所）实验室先进行痰培养,并将阳性培养物运输到地市级实验室进行药物敏感性试验（简称“县级培养地市级药敏试验模式”,模式2）.从2010年3月到2012年2月,以5个研究地区痰涂片阳性患者7733例和天津市全部涂阴患者共3426例为主要筛查对象,进行结核分枝杆菌痰培养和异烟肼、利福平、链霉素、乙胺丁醇、氧氟沙星和卡那霉素的药敏试验,分析不同人群中耐多药及广泛耐药肺结核患者的检出率、送检及检出过程的时间间隔.并根据筛查结果使用SPSS 13.0统计学软件进行描述性统计分析和卡方检验,以P＜0.05为差异有统计学意义.结果 模式1痰标本和模式2的菌株送检率分别为76.5％（3078/4026）和90.4％（2017/2232）,差异有统计学意义（x^2=183.7,P＜0.05）;但培养阳性率模式1为89.9％（2455/2730）、模式2为87.2％ （2232/2559）,差异无统计学意义（x^2=0.2234,P＞0.05）.耐药确诊时间中位数（P25,P75）为104（86,138）d,个别甚至长达1年以上.复治涂阳、新涂阳和涂阴肺结核耐多药检出率分别为17.1％（129/755）、2.1％（97/4534）和0.5％（9/1937）.结论 针对不同资源的地区可以采用县级培养模式或地市级培养模式.传统药敏试验时间长,有条件的地区宜早采用分子生物学快速检测技术.以涂阳患者为筛查对象可以发现大多数耐多药患者,资源丰富地区也可开展对涂阴患者的耐药检测.

Objective To evaluate different case finding strategies of MDR TB,and to provide evidence for developing case finding strategy appropriately.Methods According to geographic and economic conditions,Tianjin,Wanzhou,Puyang,Quzhou and Daqing were selected as study areas.The sputum specimens of smear positive pulmonary tuberculosis（PTB） cases in Tianjin,Daqing and Puyang were sent to prefecture lab for culture and drug susceptibility test （DST） （Model 1）,those in Quzhou and 6 counties （districts） were cultured in the lab at county level,and the positive cultural substance were sent to prefecture lab for DST （Model 2）.7733 cases of smear posi tive PTB in 5 areas and all 3427 cases of smear negative patients in Tianjin registered from March 2010 to February 2013 were screened with sputum culture and DST （isoniazid,rifampicin,streptomycin,ethambutol,ofloxacin and kanamycin）.Delay of diagnosis,MDRTB and XDR TB detection rate were collected and analysed by descriptive method and Chi square test by SPSS 13.0.Results Specimen examination rates of Model 1 and 2 were 76.5% （3078/4026）and 90.4% （2017/2232） respectively,and the difference had statistical significance （x^2 183.7,P〈0.05）.The culture positive rate of Model 1 and 2 were 89.9% （2455/2730） and 87.2% （2232/2559） respectively,there was no statistical significance （x^2 0.2234,P〉0.05）.The median of MDR diagnosis delay by traditional DST was 104（86,138） d,some even longer than 1 year.The detection rates from the highest to lowest were retreatment （17.1%,129/755）,new smear positive （2.1%,97/4534） and smear negative （0.5%,9/1937）.Conclusion Depending on the resources of different settings,either culture and DST by prefectural level model or culture by county level and DST by prefectural level model are reasonable.Because traditional DST takes longer period,rapid molecular test for drug resistance is recommended for developed setting.Selecting smear positive patient as the screning objects covers majority of MDR TB patients,screening MDR TB among smear negative is recommended for de veloped setting.