我国49家医院结核性脑膜炎临床诊疗现状的问卷调查分析

Diagnostic approach and management of tuberculous meningitis:a nationwide cross-sectional survey in 49 hospitals in China

目的调查分析我国不同地区医疗机构对结核性脑膜炎(tuberculous meningitis,TBM)相关诊疗资源的配置情况及对TBM患者的管理现状。方法纳入我国27个省份49家收治TBM的医院进行电子问卷调查,由主要收治TBM的相应科室的管理人员填写,调查时间为2018年9月至12月。根据问卷结果,对这些医院TBM诊治相关临床资源可及性、诊断和鉴别诊断手段、抗结核治疗、糖皮质激素治疗和相关合并症及并发症监测治疗情况进行调查和分析。计数资料以百分数表示。结果49家调研医院中,75.5%(37/49)的调研医院每年疑诊TBM不超过50例,85.7%(42/49)的医院病原学确诊的TBM患者不超过20例。计算机断层成像、磁共振成像、增强磁共振成像、脑血管造影、磁共振血管成像用来诊断及评估TBM的可及率分别为100.00%(49/49)、95.92%(47/49)、91.84%(45/49)、61.22%(30/49)、67.35%(33/49);脑脊液结核培养、脑脊液抗酸染色涂片、结核感染T淋巴细胞斑点试验可及率分别为77.55%(38/49)、95.92%(47/49)和83.67%(41/49)。利福平(100.0%,49/49)、异烟肼(100.0%,49/49)、吡嗪酰胺(98.0%,48/49)和乙胺丁醇(95.9%,47/49)是非重症TBM患者常规初始抗结核方案中常用的药物。25家(51.0%)医院抗结核治疗持续时间为18个月,17家(34.7%)为12个月。39家(79.6%)医院将异烟肼+糖皮质激素作为鞘内注射方案。24家(49.0%)医院选择地塞米松治疗,28家(57.1%)医院的糖皮质激素使用持续时间为2个月。32家(65.3%)医院未正式调查低钠血症的潜在病因,最常用的治疗低钠血症的措施为高渗盐水(83.7%,41/49)和口服钠盐治疗(71.4%,35/49)。48家(98.0%)医院最常用的检测颅内压方法为腰椎穿刺。结论调研医院收治的TBM病例呈现来源分散、病原学确诊病例少的特点。TBM诊断治疗及并发症管理均存在明显的异质性,需要制订规范性诊治方案来提升TBM的管理水平。

Objective To take a broad overview of the current allocation of diagnosis and treatment resources and management for patients with tuberculous meningitis(TBM)in 49 hospitals in China.Methods A cross-sectional survey about TBM was carried out in 49 hospitals from 27 provinces across China,by means of electronic questionnaire.The electronic questionnaire was filled by doctors in charge of the departments where TBM patients were routinely admitted from September to December 2018.The availability of medical resources,diagnosis,evaluation,treatment and surveillance in these hospitals were analyzed from the questionnaire.The count data were expressed as percentage.Results Among the 49 participating hospitals,37(75.5%)hospitals had less than 50 admissions of suspected TBM per year.Less than 20 TBM patients were confirmed by etiological diagnosis per year in 42(85.7%)participating hospitals.The availability of conventional medical imaging including computed tomography(CT),magnetic resonance imaging(MRI),enhanced MRI,cerebral angiography and magnetic resonance angiography(MRA)were 100.00%(49/49),95.92%(47/49),91.84%(45/49),61.22%(30/49)and 67.35%(33/49),respectively.The rate of access to classic etiological diagnostic methods including acid-fast bacilli smear,mycobacterial culture and T cell spot test of tuberculosis infection were 77.55%(38/49),95.92%(47/49)and 83.67%(41/49),respectively.Rifampin(100.0%,49/49),isoniazid(100.0%,49/49),pyrazinamide(98.0%,48/49)and ethambutol(95.9%,47/49)were most commonly used in initial anti-tuberculosis treatment of non-severe patients with TBM.The course of anti-tuberculosis treatment was 18 months in 25(51.0%)hospitals,and 12 months in 17(34.7%)hospitals.Intrathecal glucocorticoid and isoniazid were used in 39(79.6%)hospitals.Dexamethasone was used as part of treatment in 24(49.0%)hospitals,and the duration of glucocorticoid was about two months in 28(57.1%)hospitals.As for hyponatremia,32(65.3%)hospitals didn′t investigate the cause,and hypertonic saline(83.7%,41/49)and oral rehydration salts(71.4%,35/49)were considered as the most common treatment strategy.Lumbar puncture was most commonly used for intracranial pressure surveillance in 48(98.0%)hospitals.Conclusions The TBM cases admitted to the investigation hospitals are characterized by scattered sources and few confirmed cases of etiology.There are obvious heterogeneities in the diagnosis and treatment of TBM and the management of complications.The standardized plan for diagnosis and treatment of TBM are needed to improve the management.