The relationship between delayed or incomplete treatment and all-cause mortality in patients with tuberculosis
The relationship between delayed or incomplete treatment and all-cause mortality in patients with tuberculosis
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DOI：
10.1001/jama.276.15.1223
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发表时间：
1996-10-16
影响因子：
120.7
通讯作者：
Frieden, TR
中科院分区：
文献类型：
--
作者：
PablosMendez, A;Sterling, TR;Frieden, TR
目标。目的：分析纽约市肺结核和肺外结核患者生存的相关因素。-全市范围内肺结核病例队列的观察性研究。背景。——纽约，1991年4月，在加强控制计划之前。- 1991年4月通过培养记录的229例新诊断结核病病例。大多数患者（74%）为男性，中位年龄为37岁（范围1-89岁）。总的来说，89%属于少数群体。50%的病例存在人类免疫缺陷病毒（HIV）感染，7%的病例存在多药耐药性。21例（9%）患者未接受治疗。主要结果测量。-通过纽约市结核病登记处收集后续信息；任何原因导致的死亡都通过国家死亡指数进行核实。-到1994年10月，累积全因死亡率为44%；死亡患者的中位生存期为6.3个月（0天至3年）。根据基线临床和人口学因素调整后，最重要的死亡率基线预测因子是获得性免疫缺陷综合征（艾滋病）（hiv血清阴性患者91% vs 11%； Cox相对危险度[RR]， 7.8； 95%可信区间[CI]， 2.1-29.1）、多药耐药（全敏感病例87% vs 39%；调整RR， 5.8; 95% CI, 2.3-14.5）和缺乏治疗（81% vs 40%；调整RR， 3.1; 95% CI, 1.0-9.7）。此外，延迟1个月才开始治疗的13名艾滋病毒感染者中有11人死亡。在推荐治疗期存活的173例患者中，完成治疗的患者（66%）的后续死亡率较低（20% vs 37%； RR, 0.5; 95% CI, 0.3-0.9）。-结核病的死亡率很高，即使在没有多药耐药性但不知道感染艾滋病毒的患者中也是如此。大多数接受延迟治疗的hiv血清阳性患者死亡。多药耐药预示着更高的死亡率，而完成治疗与随后患者生存率的提高有关。
Objective.-To analyze the factors associated with survival in patients with pulmonary and extrapulmonary tuberculosis in New York City.Design.-Observational study of a citywide cohort of tuberculosis cases.Setting.-New York City, April 1991, before the strengthening of its control program.Patients.-All 229 newly diagnosed cases of tuberculosis documented by culture in April 1991. Most patients (74%) were male, and the median age was 37 years (range, 1-89 years). In all, 89% belonged to minority groups. Human immunodeficiency virus (HIV) infection was present in 50% and multidrug resistance in 7% of the cases. Twenty-one patients (9%) were not treated.Main Outcome Measures.-Follow-up information was collected through the New York City tuberculosis registry; death from any cause was verified through the National Death Index.Results.-Cumulative all-cause mortality by October 1994 was 44%; the median survival for those who died was 6.3 months (range, 0 days to 3 years). The most important baseline predictors of mortality, adjusted for baseline clinical and demographic factors, were acquired immunodeficiency syndrome (AIDS) (91% vs 11% in HIV-seronegative patients; Cox relative risk [RR], 7.8; 95% confidence interval [CI], 2.1-29.1), multidrug resistance (87% vs 39% in pansensitive cases; adjusted RR, 5.8; 95% CI, 2.3-14.5), and lack of treatment (81% vs 40%; adjusted RR, 3.1; 95% CI, 1.0-9.7). Also, 11 of 13 HIV-infected patients who started treatment after a 1-month delay died. Among 173 patients surviving the recommended treatment period, those who completed therapy (66%) had a lower subsequent mortality (20% vs 37%; RR, 0.5; 95% CI, 0.3-0.9).Conclusions.-Mortality from tuberculosis was high, even among patients without multidrug resistance who were not known to be infected with HIV. Most HIV-seropositive patients with delayed therapy died. Multidrug resistance predicted higher mortality, and treatment completion was associated with improved subsequent patient survival.