Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa.
Division of Medical Microbiology, and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
Respirology. 2018 Jan;23(1):36-45. doi: 10.1111/resp.13143. Epub 2017 Aug 29.
Tuberculosis (TB) is now the biggest infectious disease killer worldwide. Although the estimated incidence of TB has marginally declined over several years, it is out of control in some regions including in Africa. The advent of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) threatens to further destabilize control in several regions of the world. Drug-resistant TB constitutes a significant threat because it underpins almost 25% of global TB mortality, is associated with high morbidity, is a threat to healthcare workers and is unsustainably costly to treat. The advent of highly resistant TB with emerging bacillary resistance to newer drugs has raised further concern. Encouragingly, in addition to preventative strategies, several interventions have recently been introduced to curb the drug-resistant TB epidemic, including newer molecular diagnostic tools, new (bedaquiline and delamanid) and repurposed (linezolid and clofazimine) drugs and shorter and individualized treatment regimens. However, there are several controversies that surround the use of new drugs and regimens, including whether, how and to what extent they should be used, and who specifically should be treated so that outcomes are optimally improved without amplifying the burden of drug resistance, and other potential drawbacks, thus sustaining effectiveness of the new drugs. The equipoise surrounding these controversies is discussed and some recommendations are provided.
结核病（TB）是目前全球最大的传染病杀手。尽管结核病的估计发病率在几年内略有下降，但在包括非洲在内的一些地区仍处于失控状态。耐多药结核病（MDR-TB）和广泛耐药结核病（XDR-TB）的出现威胁着进一步破坏世界上几个地区的控制。耐药结核病构成了重大威胁，因为它占全球结核病死亡人数的近 25%，与高发病率相关，对医护人员构成威胁，且治疗费用高得难以承受。具有新兴细菌耐药性的高度耐药结核病的出现引起了进一步的关注。令人鼓舞的是，除了预防策略外，最近还引入了几种干预措施来遏制耐药结核病的流行，包括新的分子诊断工具、新的（贝达喹啉和德拉马尼）和重新利用的（利奈唑胺和氯法齐明）药物以及更短和个体化的治疗方案。然而，新药物和方案的使用存在一些争议，包括是否、如何以及在何种程度上使用它们，以及具体应该治疗谁，以在不扩大耐药负担的情况下优化改善结果，并避免其他潜在的缺点，从而维持新药物的有效性。讨论了这些争议的平衡点，并提供了一些建议。
