García-García M L, Sifuentes-Osornio J, Jiménez-Corona M E, Ponce-de-León A, Jiménez-Corona A, Bobadilla-del Valle M, Palacios-Martínez M, Canales G, Sanginés A, Jaramillo Y, Martínez-Gamboa A, Balandrano S, Valdespino-Gómez J L, Small P
Hospital General de Río Blanco.
Rev Invest Clin. 2001 Jul-Aug;53(4):315-23.
Tuberculosis, declared a global emergency by the World Health Organization, continues to be an important public health problem in Mexico, included in the first twenty causes of death.
To know the impact of drug resistance of Mycobacterium tuberculosis on treatment outcome, need of re-treatment and mortality in a cohort of patients with pulmonary tuberculosis receiving directly observed therapy, short course (DOTS).
We conducted a population-based study in a suburban region in Southern Mexico. People who had been coughing for more than two weeks underwent sputum acid-fast bacilli smear. Patients with a positive smear were recruited and underwent clinical exam, chest X-ray, HIV testing, and sputum cultures. Identification, drug susceptibility testing and restriction fragment length polymorphism analysis (RFLP) were performed in all isolates. Patients were followed every 12 months for new episodes of tuberculosis and vital status. Patients were referred for clinical care to the local program of tuberculosis. Deaths were corroborated with death certificates. Informed consent was obtained from participants.
Between March 1995 and February 1999, tuberculosis was diagnosed in 371 patients who were followed for an average of 32 months. M. tuberculosis was cultured from 316 patients; resistance to any drug occurred in 25.0% of isolates (primary 18.8%, acquired 49.2%); only to isoniazid in 6.8% (primary 7.3%, acquired 4.8%); to isoniazid and rifampin in 6.2% (primary 1.6%, acquired 23.8%). Patients with drug resistance had a higher probability of treatment failure (OR = 16.9, CI 95% 4.5-63.0) and patients with MDR strains had a higher probability of need of re-treatment (RR = 24.4, CI 95% 8.8-67.6), and of death (RR = 4.0, CI 95% 1.5-10.7). Additional variables were found to be associated with subsequent episodes of disease and mortality: Cocaine use, chronic disease, type of radiological lesions, HIV co-infection, non-compliance and treatment delay, as well as RFLP clustering.
In this study, we observed that drug resistance showed a severe impact on the outcome and survival; drug-resistance was the most significant factor for these negative outcomes; DOTS may not be sufficient in areas where drug resistance is considerable, and patient follow-up for longer periods of time, as compared to evaluation at the end of treatment, provides additional information which is useful for prevention and control programs.
结核病被世界卫生组织宣布为全球紧急情况，在墨西哥仍然是一个重要的公共卫生问题，位列前二十大致死原因之中。
了解结核分枝杆菌耐药性对接受直接观察下的短程治疗（DOTS）的肺结核患者队列的治疗结果、再次治疗需求和死亡率的影响。
我们在墨西哥南部的一个郊区开展了一项基于人群的研究。咳嗽超过两周的人接受痰涂片抗酸杆菌检查。痰涂片阳性的患者被招募并接受临床检查、胸部X光检查、艾滋病毒检测和痰培养。对所有分离株进行鉴定、药敏试验和限制性片段长度多态性分析（RFLP）。每12个月对患者进行随访，了解结核病新发病例和生命状态。患者被转介到当地的结核病项目接受临床治疗。死亡情况通过死亡证明进行核实。获得了参与者的知情同意。
1995年3月至1999年2月期间，371例患者被诊断为结核病，平均随访32个月。316例患者培养出结核分枝杆菌；25.0%的分离株对任何药物耐药（原发性耐药18.8%，获得性耐药49.2%）；仅对异烟肼耐药的占6.8%（原发性耐药7.3%，获得性耐药4.8%）；对异烟肼和利福平耐药的占6.2%（原发性耐药1.6%，获得性耐药23.8%）。耐药患者治疗失败的概率更高（OR = 16.9，95%置信区间4.5 - 63.0），耐多药菌株患者再次治疗的需求更高（RR = 24.4，95%置信区间8.8 - 67.6），死亡概率也更高（RR = 4.0，95%置信区间1.5 - 10.7）。还发现其他变量与疾病的后续发作和死亡率相关：使用可卡因、慢性病、放射学病变类型、艾滋病毒合并感染、不依从和治疗延迟，以及RFLP聚类。
在本研究中，我们观察到耐药性对治疗结果和生存有严重影响；耐药性是这些负面结果的最重要因素；在耐药情况相当严重的地区，DOTS可能不够充分，与治疗结束时的评估相比，对患者进行更长时间的随访可提供对预防和控制项目有用的额外信息。
