Gandhi Neel R, Moll Anthony, Sturm A Willem, Pawinski Robert, Govender Thiloshini, Lalloo Umesh, Zeller Kimberly, Andrews Jason, Friedland Gerald
AIDS Program, Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
Lancet. 2006 Nov 4;368(9547):1575-80. doi: 10.1016/S0140-6736(06)69573-1.
The epidemics of HIV-1 and tuberculosis in South Africa are closely related. High mortality rates in co-infected patients have improved with antiretroviral therapy, but drug-resistant tuberculosis has emerged as a major cause of death. We assessed the prevalence and consequences of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis in a rural area in KwaZulu Natal, South Africa.
We undertook enhanced surveillance for drug-resistant tuberculosis with sputum culture and drug susceptibility testing in patients with known or suspected tuberculosis. Genotyping was done for isolates resistant to first-line and second-line drugs.
From January, 2005, to March, 2006, sputum was obtained from 1539 patients. We detected MDR tuberculosis in 221 patients, of whom 53 had XDR tuberculosis. Prevalence among 475 patients with culture-confirmed tuberculosis was 39% (185 patients) for MDR and 6% (30) for XDR tuberculosis. Only 55% (26 of 47) of patients with XDR tuberculosis had never been previously treated for tuberculosis; 67% (28 of 42) had a recent hospital admission. All 44 patients with XDR tuberculosis who were tested for HIV were co-infected. 52 of 53 patients with XDR tuberculosis died, with median survival of 16 days from time of diagnosis (IQR 6-37) among the 42 patients with confirmed dates of death. Genotyping of isolates showed that 39 of 46 (85%, 95% CI 74-95) patients with XDR tuberculosis had similar strains.
MDR tuberculosis is more prevalent than previously realised in this setting. XDR tuberculosis has been transmitted to HIV co-infected patients and is associated with high mortality. These observations warrant urgent intervention and threaten the success of treatment programmes for tuberculosis and HIV.
南非的HIV-1疫情与结核病密切相关。联合感染患者的高死亡率随着抗逆转录病毒疗法有所改善，但耐多药结核病已成为主要死因。我们评估了南非夸祖鲁-纳塔尔省一个农村地区耐多药（MDR）和广泛耐药（XDR）结核病的患病率及后果。
我们对已知或疑似结核病患者进行痰培养和药敏试验，以加强对耐药结核病的监测。对耐一线和二线药物的分离株进行基因分型。
2005年1月至2006年3月，从1539名患者中获取了痰液。我们在221名患者中检测到耐多药结核病，其中53人患有广泛耐药结核病。在475名培养确诊的结核病患者中，耐多药结核病的患病率为39%（185例患者），广泛耐药结核病的患病率为6%（30例）。广泛耐药结核病患者中只有55%（47例中的26例）此前从未接受过结核病治疗；67%（42例中的28例）近期曾住院治疗。所有接受HIV检测的44例广泛耐药结核病患者均合并感染。53例广泛耐药结核病患者中有52例死亡，42例有确诊死亡日期的患者从诊断时起的中位生存期为16天（四分位间距6 - 37天）。分离株的基因分型显示，46例广泛耐药结核病患者中有39例（85%，95%可信区间74 - 95）具有相似菌株。
在这种情况下，耐多药结核病比之前认识到的更为普遍。广泛耐药结核病已传播到合并感染HIV的患者中，并与高死亡率相关。这些观察结果需要紧急干预，并对结核病和HIV治疗方案的成功构成威胁。
