O'Brien R J
Tuberculosis Programme, World Health Organization, Geneva, Switzerland.
Semin Respir Infect. 1994 Jun;9(2):104-12.
Drug-resistant Mycobacterium tuberculosis inevitably arises from inadequate or inappropriate drug taking or drug prescribing, effectively resulting in monotherapy. This may occur in the patient being treated (acquired resistance) or in a patient who has been infected by another patient with drug resistant tuberculosis (primary resistance). There is some evidence that multidrug-resistant tuberculosis, ie, resistance to both isoniazid and rifampin, is increasing in the United States and in other countries where unsupervised treatment with rifampin has been common. Human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS), although not causing drug-resistant tuberculosis, have certainly magnified the problem, especially in New York City. Treatment of drug-resistant tuberculosis must be based on results of drug susceptibility studies. Patients with isolated isoniazid-resistant tuberculosis respond well to modified short-course therapy with rifampin, ethambutol, and pyrazinamide. Multidrug-resistant disease is more difficult to treat, although most patients will respond to regimens of second-line drugs if the infecting organisms are susceptible to these agents. Drug-resistant tuberculosis can be prevented by accurate identification of patients with newly diagnosed tuberculosis who may be at increased risk of primary drug resistance, the administration of an appropriate treatment regimen to all newly diagnosed patients, the application of fully supervised therapy during at least the initial phase of treatment, the use of combination preparations of drugs, and the proper management of failure and relapse cases.
耐药结核分枝杆菌不可避免地源于用药不足、用药不当或处方不当，实际上导致了单一疗法。这可能发生在正在接受治疗的患者身上（获得性耐药），也可能发生在被另一名耐药结核病患者感染的患者身上（原发性耐药）。有证据表明，耐多药结核病，即对异烟肼和利福平均耐药，在美国以及其他一些普遍存在利福平无监督治疗的国家呈上升趋势。人类免疫缺陷病毒（HIV）感染和获得性免疫缺陷综合征（AIDS）虽然不会导致耐药结核病，但肯定加剧了这一问题，尤其是在纽约市。耐药结核病的治疗必须基于药敏试验结果。单纯异烟肼耐药的结核病患者对利福平、乙胺丁醇和吡嗪酰胺的改良短程疗法反应良好。耐多药疾病更难治疗，不过如果感染的病原体对二线药物敏感，大多数患者对二线药物治疗方案会有反应。通过准确识别新诊断结核病患者中可能存在原发性耐药风险增加的患者、对所有新诊断患者给予适当的治疗方案、至少在治疗初期实施全程监督治疗、使用药物联合制剂以及妥善处理治疗失败和复发病例，可以预防耐药结核病。
