南非广泛耐药结核病患者的早期治疗结局和 HIV 状况：一项回顾性队列研究。

Early treatment outcomes and HIV status of patients with extensively drug-resistant tuberculosis in South Africa: a retrospective cohort study.

机构信息

Lung Infection and Immunity Unit, Division of Pulmonology and University of Cape Town Lung Institute, Department of Medicine, Cape Town, South Africa.

出版信息

Lancet. 2010 May 22;375(9728):1798-807. doi: 10.1016/S0140-6736(10)60492-8.

DOI:10.1016/S0140-6736(10)60492-8

PMID:20488525

Abstract

BACKGROUND

Data from Kwazulu Natal, South Africa, suggest that almost all patients with extensively drug-resistant (XDR) tuberculosis are HIV-positive, with a fatal outcome. Since, there are few data for the treatment-related outcomes of XDR tuberculosis in settings with a high HIV prevalence, we investigated the associations of these diseases in such settings to formulate recommendations for control programmes.

METHODS

In a retrospective cohort study, we analysed the case records of patients (>16 years old) with XDR tuberculosis (culture-proven at diagnosis) between August, 2002, and February, 2008, at four designated provincial treatment facilities in South Africa. We used Cox proportional hazards regression models to assess risk factors associated with the outcomes-mortality and culture conversion.

FINDINGS

195 of 227 patients were analysed. 21 died before initiation of any treatment, and 174 patients (82 with HIV infection) were treated. 62 (36%) of these patients died during follow-up. The number of deaths was not significantly different in patients with or without HIV infection: 34 (41%) of 82 versus 28 (30%) of 92 (p=0.13). Treatment with moxifloxacin (hazard ratio 0.11, 95% CI 0.01-0.82; p=0.03), previous culture-proven multidrug-resistant tuberculosis (5.21, 1.93-14.1; p=0.001), and number of drugs used in a regimen (0.59, 0.45-0.78, p<0.0001) were independent predictors of death. Fewer deaths occurred in patients with HIV infection given highly active antiretroviral therapy than in those who were not (0.38, 0.18-0.80; p=0.01). 33 (19%) of 174 patients showed culture conversion, of which 23 (70%) converted within 6 months of initiation of treatment.

INTERPRETATION

In South Africa, patients with XDR tuberculosis, a substantial proportion of whom are not infected with HIV, have poor management outcomes. Nevertheless, survival in patients with HIV infection is better than previously reported. The priorities for the country are still prevention of XDR tuberculosis, and early detection and management of multidrug-resistant and XDR tuberculosis through strengthened programmes and laboratory capacity.

FUNDING

South African Medical Research Council, European Union Framework 7 program, and European Developing Countries Clinical Trials Partnership.

摘要

背景

来自南非夸祖鲁-纳塔尔省的数据表明，几乎所有广泛耐药（XDR）结核病患者都是 HIV 阳性，且结局致命。由于在 HIV 流行率较高的环境中，有关 XDR 结核病治疗相关结局的数据较少，我们对这些疾病在这些环境中的关联进行了研究，以便为控制规划制定建议。

方法

在一项回顾性队列研究中，我们分析了 2002 年 8 月至 2008 年 2 月在南非四个指定省级治疗机构诊断为 XDR 结核病（经培养确诊）的患者（年龄>16 岁）的病历。我们使用 Cox 比例风险回归模型评估与结局（死亡率和培养转换）相关的风险因素。

结果

对 227 例患者中的 195 例进行了分析。21 例患者在开始任何治疗前死亡，174 例患者（82 例 HIV 感染）接受了治疗。在随访期间，有 62 例（36%）患者死亡。HIV 感染者和非感染者的死亡人数无显著差异：82 例中有 34 例（41%），92 例中有 28 例（30%）（p=0.13）。莫西沙星治疗（风险比 0.11，95%CI 0.01-0.82；p=0.03）、既往培养证实的耐多药结核病（5.21，1.93-14.1；p=0.001）和方案中使用的药物数量（0.59，0.45-0.78，p<0.0001）是死亡的独立预测因素。接受高效抗逆转录病毒治疗的 HIV 感染者比未接受治疗的患者死亡人数更少（0.38，0.18-0.80；p=0.01）。174 例患者中有 33 例（19%）培养转换，其中 23 例（70%）在治疗开始后 6 个月内转换。