Blizard Institute, Queen Mary, University of London, London, UK Department of Infectious Diseases, Imperial College London, London, UK Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
N.V. Postnikov Samara Region Clinical Tuberculosis Dispensary, Samara, Russia.
Thorax. 2016 Sep;71(9):854-61. doi: 10.1136/thoraxjnl-2015-207638. Epub 2016 Mar 24.
The quality of care for patients with TB in Eastern Europe has improved significantly; nevertheless drug resistance rates remain high. We analysed survival in a cohort of patients with multidrug-resistant and extensively drug-resistant (MDR-/XDR-) TB from Latvia, Lithuania, Estonia and Bucharest city.
Consecutive adult new and retreatment patients with culture-confirmed pulmonary MDR-TB registered for treatment in 2009 (and in 2007 in Latvia) were enrolled; prospective survival information was collected.
A total of 737 patients were included into the cohort. Of all MDR-TB cases, 46% were newly diagnosed; 56% of all MDR-TB cases had no additional resistance to fluoroquinolones or injectable agents, 33% had pre-XDR-TB and 11% XDR-TB. Median survival was 5.9 years in patients with MDR-TB and XDR-TB; 1.9 years in patients coinfected with HIV. Older age, male gender, alcohol abuse, retirement, co-morbidities, extrapulmonary involvement and HIV coinfection independently worsened survival. Inclusion of fluoroquinolones and injectable agents improves survival in patients with MDR-TB. Pre-XDR and XDR status did not significantly shorten survival as long as fluoroquinolones and injectable agents were part of the regimen. Moxifloxacin seems to improve survival in ofloxacin-susceptible patients when compared with older generation fluoroquinolones.
The burden of additional resistances in patients with MDR-TB is high likely due to primary transmission of resistant strains. Social and programmatic factors including management of alcohol dependency, expansion of HIV testing and antiretroviral treatment need to be addressed in order to achieve cure and to interrupt transmission. The role of last generation fluoroquinolones and injectable agents in treatment of patients with pre-XDR and XDR-TB needs to be further investigated.
东欧国家的结核病患者治疗质量有了显著提高，但耐药率仍然很高。我们分析了来自拉脱维亚、立陶宛、爱沙尼亚和布加勒斯特的耐多药和广泛耐药（MDR-/XDR-）结核病患者队列的生存情况。
连续纳入了 2009 年（拉脱维亚为 2007 年）登记治疗的培养确诊为肺 MDR-TB 的成人新发病例和复治病例；前瞻性收集了生存信息。
共纳入了 737 例患者。所有 MDR-TB 病例中，46%为新诊断病例；56%的 MDR-TB 病例无氟喹诺酮类药物或注射剂的额外耐药，33%为预广泛耐药，11%为广泛耐药。MDR-TB 和 XDR-TB 患者的中位生存时间为 5.9 年；HIV 合并感染患者为 1.9 年。年龄较大、男性、酒精滥用、退休、合并症、肺外受累和 HIV 合并感染均独立地使生存恶化。包含氟喹诺酮类药物和注射剂可改善 MDR-TB 患者的生存。只要方案中包含氟喹诺酮类药物和注射剂，预广泛耐药和广泛耐药状态并不显著缩短生存时间。与老一代氟喹诺酮类药物相比，莫西沙星似乎可改善氧氟沙星敏感患者的生存。
MDR-TB 患者的附加耐药负担很高，可能是由于耐药菌株的原发传播。需要解决社会和规划因素，包括管理酒精依赖、扩大 HIV 检测和抗逆转录病毒治疗，以实现治愈和阻断传播。需要进一步研究最后一代氟喹诺酮类药物和注射剂在治疗预广泛耐药和广泛耐药结核病患者中的作用。
