The Prevalence and Drug Sensitivity of Tuberculosis among Patients Dying in Hospital in KwaZulu-Natal, South Africa: A Postmortem Study
The Prevalence and Drug Sensitivity of Tuberculosis among Patients Dying in Hospital in KwaZulu-Natal, South Africa: A Postmortem Study
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DOI：
10.1371/journal.pmed.1000296
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发表时间：
2010-06-01
期刊：
影响因子：
15.8
通讯作者：
Wilson, Douglas
中科院分区：
文献类型：
--
作者：
Cohen, Ted;Murray, Megan;Wilson, Douglas
背景：结核病是南非死亡通报的主要死因，但在艾滋病毒高流行的背景下，结核病的准确诊断具有挑战性。我们对2008年10月至2009年8月期间在夸祖鲁-纳塔尔省一家公立医院死亡的年轻人进行了有限的尸检，以估计可归因于结核病的死亡人数。方法与发现：我们研究了240例在Edendale医院入院后死亡的成年住院患者（年龄在20-45岁）的代表性样本。有限的尸检包括通过肺、肝和脾穿刺活检收集呼吸道分泌物和组织。用荧光显微镜检查标本是否有抗酸杆菌，并在液体培养基中培养；检测结核分枝杆菌阳性培养物对一线和二线抗生素的药物敏感性。我们的研究队列中有94%的人在死亡时呈HIV血清阳性，50%的死者在死亡时呈结核培养阳性。50%的参与者在死亡时正在接受结核病治疗，这些接受治疗的个体中有58%在死亡时仍保持培养阳性。在未接受结核病治疗的50%患者中，42%的患者培养呈阳性。17%的阳性培养物对异烟肼和利福平均耐药（即多重耐药）；在首次结核病治疗开始阶段死亡的患者中，有16%感染了耐多药杆菌。结论：我们的研究结果揭示了夸祖鲁-纳塔尔省艾滋病毒阳性个体中结核病的巨大死亡率。尽管接受了结核病治疗，但大多数仍呈培养阳性的死者感染了全易感结核分枝杆菌，这表明结核病的诊断太晚，无法改变感染的致命过程。在这种情况下死亡的艾滋病毒合并感染者中，也存在未被发现的耐多药结核病的重大负担。在这种情况下，迫切需要改善结核病早期诊断和加速开始治疗的新公共卫生方法。
Background: Tuberculosis is the leading cause of death in South Africa by death notification, but accurate diagnosis of tuberculosis is challenging in this setting of high HIV prevalence. We conducted limited autopsies on young adults dying in a single public hospital in the province of KwaZulu-Natal between October 2008 and August 2009 in order to estimate the magnitude of deaths attributable to tuberculosis.Methods and Findings: We studied a representative sample of 240 adult inpatients (aged 20-45 years) dying after admission to Edendale Hospital. Limited autopsies included collection of respiratory tract secretions and tissue by needle core biopsies of lung, liver, and spleen. Specimens were examined by fluorescent microscopy for acid-fast bacilli and cultured in liquid media; cultures positive for M. tuberculosis were tested for drug susceptibility to first-and second-line antibiotics. Ninety-four percent of our study cohort was HIV seropositive and 50% of decedents had culture-positive tuberculosis at the time of death. Fifty percent of the participants were on treatment for tuberculosis at the time of death and 58% of these treated individuals remained culture positive at the time of death. Of the 50% not receiving tuberculosis treatment, 42% were culture positive. Seventeen percent of all positive cultures were resistant to both isoniazid and rifampin (i.e., multidrug resistant); 16% of patients dying during the initiation phase of their first ever course of tuberculosis treatment were infected with multidrug-resistant bacilli.Conclusions: Our findings reveal the immense toll of tuberculosis among HIV-positive individuals in KwaZulu-Natal. The majority of decedents who remained culture positive despite receiving tuberculosis treatment were infected with pansusceptible M. tuberculosis, suggesting that the diagnosis of tuberculosis was made too late to alter the fatal course of the infection. There is also a significant burden of undetected multidrug-resistant tuberculosis among HIV-coinfected individuals dying in this setting. New public health approaches that improve early diagnosis of tuberculosis and accelerate the initiation of treatment are urgently needed in this setting.