Kumar R S, Kumar A M V, Claassens M, Banurekha V V, Sekar G, Venkatesan P, Swaminathan S
National Institute for Research in Tuberculosis, Chennai, India.
International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India;
Int J Tuberc Lung Dis. 2014 Apr;18(4):449-53. doi: 10.5588/ijtld.13.0429.
National Institute for Research in Tuberculosis, India.
To assess, among new culture-confirmed smear-positive pulmonary tuberculosis (TB) patients, the proportion of follow-up smear-positives that were culture-negative (S+C-) by month of follow-up examination, human immunodeficiency virus (HIV) status, pre-treatment drug susceptibility status and smear grading.
We extracted follow-up smear (fluorescence microscopy) and culture (Löwenstein-Jensen) results of patients enrolled in clinical trials from January 2000 to August 2012 and treated with the WHO Category I regimen (2EHRZ3/4HR3).
Of 520 patients, including 176 who were HIV-infected, respectively 199, 81, 47 and 43 were smear-positive at months 2, 4, 5 and 6; of these, respectively 138 (69%), 62 (75%), 32 (68%) and 27 (63%) were culture-negative. The S+C- phenomenon was more pronounced among '1+ positive' patients than in 2+ or 3+ positive patients and in 'pan-susceptible' patients than in those with any resistance, and did not vary by HIV status.
Nearly two thirds of patients with follow-up smears positive at months 5 and 6 were culture-negative. Starting multidrug-resistant TB (MDR-TB) treatment empirically based on smear results, even in resource-limited settings, is incorrect and can have hazardous consequences. There is an urgent need to revisit the WHO recommendation concerning empirical MDR-TB treatment.
印度国家结核病研究所。
在新确诊的痰涂片阳性肺结核患者中，按随访检查月份、人类免疫缺陷病毒（HIV）状态、治疗前药物敏感性状态和涂片分级，评估随访痰涂片阳性但培养阴性（S+C-）的比例。
我们提取了2000年1月至2012年8月参加临床试验并接受世界卫生组织I类方案（2EHRZ3/4HR3）治疗的患者的随访痰涂片（荧光显微镜检查）和培养（罗氏培养基）结果。
520例患者中，包括176例HIV感染者，在第2、4、5和6个月时分别有199、81、47和43例痰涂片阳性；其中，分别有138例（69%）、62例（75%）、32例（68%）和27例（63%）培养阴性。S+C-现象在“1+阳性”患者中比在2+或3+阳性患者中更明显，在“全敏感”患者中比在有任何耐药性的患者中更明显，且不随HIV状态而变化。
在第5和6个月随访痰涂片阳性的患者中，近三分之二培养阴性。即使在资源有限的环境中，基于痰涂片结果经验性启动耐多药结核病（MDR-TB）治疗也是不正确的，可能会产生有害后果。迫切需要重新审视世界卫生组织关于经验性MDR-TB治疗的建议。
