痰涂片和痰培养阴转作为耐多药结核病患者治疗结局预测指标有效性的比较

Comparison of the validity of smear and culture conversion as a prognostic marker of treatment outcome in patients with multidrug-resistant tuberculosis

目的评价治疗二月末和六月末痰涂片和痰培养阴转对耐多药结核病(Multidrug-resistant tuberculosis,MDR-TB)患者治疗结局预测的有效性。方法2010年1月1日—2016年6月30日江苏省结核病患者信息管理系统登记的镇江、南通、徐州和连云港市的MDR-TB患者为研究对象,收集每个患者二月末和六月末痰涂片和痰培养阴转的信息,通过分析痰菌阴转情况,评价治疗结局预测的灵敏度、特异度、阳性预测值及阴性预测值和受试者工作特征曲线(Receiver Operating Characteristic Curve,ROC),比较两时期痰涂片和痰培养对治疗结局的预测效率。结果共纳入MDR-TB患者440例,治疗成功率74.8%。二月末痰培养阴转预测灵敏度(88.1%)、特异度(54.1%)、阳性预测值(85.0%)和阴性预测值(60.6%)均高于痰涂片(分别为81.8%、48.6%、82.5%和47.4%);六月末痰培养法阴转预测灵敏度(94.5%)、特异度(62.6%)、阳性预测值(89.3%)和阴性预测值(77.5%)均高于痰涂片法(分别为93.6%、53.5%、86.9%和71.6%)。二月末和六月末痰涂片和痰培养阴转的ROC曲线下面积分别为0.652和0.711(P=0.06)以及0.736和0.786(P=0.05),痰涂片阴转的诊断价值低于痰培养,差别在临界值附近。结论痰涂片阴转预测MDR-TB患者治疗结局的有效性低于痰培养。建议采纳WHO建议,同时使用痰涂片和痰培养监测MDR-TB患者的疗效,以便更有效地预测治疗结局。

Objective To evaluate the predictive effect of 2-month and 6-month sputum smears and sputum culture in the treatment of Multi-drug resistant tuberculosis(MDR-TB)patients.Methods All MDR-TB patients registered in TB Management Information System in Zhenjiang,Nantong,Xuzhou and Lianyungang cities from Jan 1 st,2010 to Junth 30 th,2016 were enrolled in our study.We collected information of 2-month and 6-month sputum smears and sputum culture.The sensitivity,specificity,positive and negative predictive value and Receiver Operating Characteristic Curve(ROC)of sputum conversion in 2-month and 6-month were calculated to compare the predictive efficiency of sputum smear and sputum culture.Results A total of 440 MDR-TB patients who met the inclusion criteria were included the treatment success rate was 74.8%.The sensitivity(88.1%),specificity(54.1%),positive predictive value(85.0%)and negative predictive value(60.6%)of 2-month sputum culture were all higher than those of smear(81.8%,48.6%,82.5%and 47.4%,respectively).The sensitivity(94.5%),specificity(62.6%),positive predictive value(89.3%)and negative predictive value(77.5%)of the6-month sputum culture were all higher than those of the smear(93.6%,53.5%,86.9%and 71.6%,respectively).The area under the ROC(AUC)of 2-month and 6-month of sputum smear and culture were 0.652,0.711(P=0.06)and 0.736,0.786(P=0.05),respectively.The differences were near the critical value.Conclusion Sputum smear conversion rate was less effective than sputum culture in predicting treatment outcomes in MDR-TB patients.And we support WHO recommendation that both sputum smears and sputum culture examinations,rather than sputum smears alone for monitoring the efficacy of MDR-TB patients for a better prediction of successful treatment outcomes.