Jain Anil K, Jain Pragya, Jaggi Karan, Suresh Abhimanyu, Yadav Manish, Gain Amartya, Gupta Himanshu
University College of Medical Sciences, University of Delhi, A10 Part B, Ashok Nagar, Ghaziabad, 201002 India.
Indian J Orthop. 2024 Apr 22;58(6):661-668. doi: 10.1007/s43465-024-01138-y. eCollection 2024 Jun.
Drug resistant (DR) osteoarticular TB (OATB) is a challenge in view of it being deep seated lesion and paucibacillary disease. Case definition, investigation protocol, treatment of proven DR and those cases where DR could not be demonstrated lacks clarity and evidence. Hence, a series of studies were conducted to develop an algorithm to investigate and treat therapeutically refractory disease (TRD) or presumptive drug resistance (PDR) cases of OATB.
6 studies were conducted. Study one and two evaluated criteria to label TRD/PDR. Three subsequent studies were conducted where TDR/PDR or fresh cases of OATB cases were investigated by AFB smear, Bactec/liquid culture, histology and genotypic DST by CBNAAT & LPA. Sixth study was a retrospective evaluation of all DR cases treated for proven or clinical drug resistance (CDR).
Patient of bone/spine TB on ATT for 5 months or more show poor clinico-radiological treatment response as worsening of lesion, increased spinal deformity, persistent discharging sinus/ulcer, appearance of fresh lesion, recurrence of previous lesion, wound dehiscence of post-operative surgical scar cab labelled as PDR cases. These cases on histology ascertained TB and were proven DR on genotypic and phenotypic DST and are treated successfully. The patients of histologically ascertained TB and no/indeterminate phenotypic and genotypic DST were successfully treated as clinical drug resistance on MDR protocol.
We described an algorithm. We must suspect PDR(TRD) based on criteria described. The tissue must be procured and submitted for AFB smear, histology and phenotypic and genotypic DST for diagnosis of TB. Genotypic and phenotypic DST will be useful to prove (90% instances) type of drug resistance. Remaining on strong clinical suspicion of DR and yet inconclusive on phenotypic/genotypic DST (<10%), may be treated as CDR as MDR. The adverse drug reactions and hepatic side-effects should be monitored diligently and these cases to be treated till healed status is demonstrated.
鉴于耐药性骨关节炎结核病（OATB）是深部病变且为少菌型疾病，它是一项挑战。病例定义、调查方案、已证实的耐药病例以及无法证实耐药的病例的治疗缺乏明确性和证据。因此，开展了一系列研究以制定一种算法，用于调查和治疗难治性疾病（TRD）或疑似耐药性（PDR）的OATB病例。
进行了6项研究。研究一和研究二评估了标记TRD/PDR的标准。随后进行了三项研究，其中通过抗酸杆菌涂片、Bactec/液体培养、组织学以及CBNAAT和LPA进行基因分型药敏试验（DST），对TDR/PDR或新的OATB病例进行调查。第六项研究是对所有因已证实的或临床耐药性（CDR）而接受治疗的耐药病例进行回顾性评估。
接受抗结核治疗5个月或更长时间的骨/脊柱结核患者表现出较差的临床放射学治疗反应，如病变恶化、脊柱畸形增加、持续性排脓窦道/溃疡、新病变出现、既往病变复发、术后手术疤痕伤口裂开，这些可标记为PDR病例。这些病例经组织学确诊为结核病，经基因分型和表型DST证实为耐药，并成功治愈。组织学确诊为结核病但表型和基因分型DST无/不确定的患者，按照耐多药方案作为临床耐药性成功治疗。
我们描述了一种算法。我们必须根据所述标准怀疑PDR（TRD）。必须获取组织并提交进行抗酸杆菌涂片、组织学以及表型和基因分型DST以诊断结核病。基因分型和表型DST将有助于证明（90%的情况）耐药类型。其余强烈怀疑耐药但表型/基因分型DST仍无定论（<10%）的情况，可作为耐多药的临床耐药性进行治疗。应密切监测药物不良反应和肝脏副作用，这些病例应治疗至显示愈合状态。
