Finnell S Maria E, Christenson John C, Downs Stephen M
Indiana University School of Medicine, Children's Health Services Research, Department of Pediatrics, HITS Building, Room 1020B, 410 W 10th St, Indianapolis, IN 46202, USA.
Pediatrics. 2009 Mar;123(3):816-22. doi: 10.1542/peds.2008-0433.
Guidelines for latent tuberculosis infection do not consider drug-resistance patterns when recommending treatment for immigrant children.
The purpose of this research was to decide at what rate of isoniazid resistance a different regimen other than isoniazid for 9 months should be considered.
We constructed a decision tree by using published data. We studied 3 regimens considered to be effective for susceptible organisms: (1) isoniazid for 9 months, (2) rifampin for 6 months, and (3) isoniazid for 9 months plus rifampin for 6 months. In addition, we evaluated a regimen of isoniazid and rifampin for 3 months. Our base case was a 2-year-old child from Russia with a tuberculin skin test reaction of 12 mm. We assumed a societal perspective and expressed results as cost and cost per case of tuberculosis prevented. We conducted sensitivity analyses to test the stability of our model.
In our baseline analysis, rifampin was the least costly treatment regimen for any child arriving from an area with an isoniazid-resistance rate of >/=11%. Treatment with isoniazid plus rifampin was the most effective but would cost more than $1 million per reactivation case prevented. Isoniazid would become the least costly regimen if any of the following thresholds were met: rifampin resistance given isoniazid resistance of more than 82%; rifampin resistance given no isoniazid resistance of >9%; cost of rifampin more than $47/month; effectiveness of rifampin lower than 63%; effectiveness of isoniazid higher than 74%; and cost of pulmonary tuberculosis less than $7661. Isoniazid and rifampin for 3 months was the least costly for all cases from areas with isoniazid resistance of <80% as long as the regimen's effectiveness was >50% for susceptible bacteria. However, this assumption remains to be proven.
Because of the high prevalence of isoniazid resistance, rifampin should be considered for children with latent tuberculosis infection originating from countries with >11% isoniazid resistance.
潜伏性结核感染的治疗指南在为移民儿童推荐治疗方案时未考虑耐药模式。
本研究的目的是确定异烟肼耐药率达到何种程度时应考虑采用异烟肼以外的其他治疗方案进行9个月的治疗。
我们利用已发表的数据构建了一个决策树。我们研究了3种被认为对敏感菌有效的治疗方案：（1）异烟肼治疗9个月；（2）利福平治疗6个月；（3）异烟肼治疗9个月加利福平治疗6个月。此外，我们还评估了异烟肼和利福平联合治疗3个月的方案。我们的基础病例是一名来自俄罗斯的2岁儿童，结核菌素皮肤试验反应为12毫米。我们从社会角度进行分析，并将结果表示为成本以及每预防一例结核病的成本。我们进行了敏感性分析以检验模型的稳定性。
在我们的基线分析中，对于任何来自异烟肼耐药率≥11%地区的儿童，利福平是成本最低的治疗方案。异烟肼加利福平治疗是最有效的，但每预防一例再激活病例的成本将超过100万美元。如果满足以下任何一个阈值，异烟肼将成为成本最低的方案：在异烟肼耐药率超过82%的情况下利福平耐药；在无异烟肼耐药的情况下利福平耐药率>9%；利福平成本超过47美元/月；利福平有效性低于63%；异烟肼有效性高于74%；以及肺结核成本低于7661美元。只要该方案对敏感菌的有效性>50%，对于所有来自异烟肼耐药率<80%地区的病例，异烟肼和利福平联合治疗3个月是成本最低的。然而，这一假设仍有待证实。
由于异烟肼耐药率较高，对于来自异烟肼耐药率>11%国家的潜伏性结核感染儿童应考虑使用利福平治疗。
