Pablos-Méndez A, Knirsch C A, Barr R G, Lerner B H, Frieden T R
Division of General Medicine, School of Public Health, Columbia University, New York, New York, USA.
Am J Med. 1997 Feb;102(2):164-70. doi: 10.1016/s0002-9343(96)00402-0.
Poor adherence to antituberculosis treatment is the most important obstacle to tuberculosis control.
To identify and analyze predictors and consequences of nonadherence to antituberculosis treatment.
Retrospective study of a citywide cohort of 184 patients with tuberculosis in New York City, newly diagnosed by culture in April 1991-before the strengthening of its control program-and followed up through 1994. Follow-up information was collected through the New York City tuberculosis registry. Nonadherence was defined as treatment default for at least 2 months.
Eighty-eight of the 184 (48%) patients were nonadherent. Greater nonadherence was noted among blacks (unadjusted relative risk [RR] 3.0, 95% confidence interval [CI] 1.1 to 8.6, compared with whites), injection drug users (RR 1.5, 95% CI 1.1 to 2.0), homeless (RR 1.4, 95% CI 1.0 to 1.8), alcoholics (RR 1.4, 95% CI 1.0 to 1.9), and HIV-infected patients (RR 1.4, 95% CI 1.1 to 1.9); also, census-derived estimates of household income were lower among nonadherent patients (P = 0.018). In multivariate analysis, only injection drug use and homelessness predicted nonadherence, yet 46 (39%) of 117 patients who were neither homeless nor drug users were nonadherent. Nonadherent patients took longer to convert to negative culture (254 versus 64 days, P < 0.001), were more likely to acquire drug resistance (RR 5.6, 95% CI 0.7 to 44.2), required longer treatment regimens (560 versus 324 days, P < 0.0001), and were less likely to complete treatment (RR 0.5, 95% CI 0.4 to 0.7). There was no association between treatment adherence and all-cause mortality.
In the absence of public health intervention, half the patients defaulted treatment for 2 months or longer. Although common among the homeless and injection drug users, the problem occurred frequently and unpredictably in other patients. Nonadherence may contribute to the spread of tuberculosis and the emergence of drug resistance, and may increase the cost of treatment. These data lend support to directly observed therapy in tuberculosis.
对抗结核治疗的依从性差是结核病控制的最重要障碍。
确定并分析抗结核治疗不依从的预测因素及后果。
对纽约市184例结核病患者进行回顾性研究，这些患者于1991年4月通过培养新确诊（在其控制项目加强之前），并随访至1994年。随访信息通过纽约市结核病登记处收集。不依从定义为治疗中断至少2个月。
184例患者中有88例（48%）不依从。黑人的不依从性更高（未调整相对风险[RR]3.0，95%置信区间[CI]1.1至8.6，与白人相比）、注射吸毒者（RR 1.5，95% CI 1.1至2.0）、无家可归者（RR 1.4，95% CI 1.0至1.8）、酗酒者（RR 1.4，95% CI 1.0至1.9）以及感染HIV的患者（RR 1.4，95% CI 1.1至1.9）；此外，不依从患者根据人口普查得出的家庭收入估计较低（P = 0.018）。在多变量分析中，只有注射吸毒和无家可归可预测不依从，但在117例既无家可归也非吸毒者的患者中，有46例（39%）不依从。不依从患者转为培养阴性所需时间更长（254天对64天，P < 0.001），更有可能获得耐药性（RR 5.6，95% CI 0.7至44.2），需要更长的治疗疗程（560天对324天，P < 0.0001），且完成治疗的可能性更小（RR 0.5，95% CI 0.4至0.7）。治疗依从性与全因死亡率之间无关联。
在没有公共卫生干预的情况下，一半的患者治疗中断2个月或更长时间。尽管在无家可归者和注射吸毒者中常见，但该问题在其他患者中也经常且不可预测地出现。不依从可能导致结核病传播和耐药性出现，并可能增加治疗成本。这些数据支持在结核病治疗中采用直接观察疗法。
