Predictors of Multidrug- and Extensively Drug-Resistant Tuberculosis in a High HIV Prevalence Community
Predictors of Multidrug- and Extensively Drug-Resistant Tuberculosis in a High HIV Prevalence Community
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DOI：
10.1371/journal.pone.0015735
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发表时间：
2010-12-29
期刊：
影响因子：
3.7
通讯作者：
Gandhi, Neel R.
中科院分区：
文献类型：
--
作者：
Andrews, Jason R.;Shah, N. Sarita;Gandhi, Neel R.
背景资料：耐多药（MDR）和广泛耐药（XDR）结核病（TB）出现在艾滋病毒高流行率环境中，这些环境通常缺乏诊断结核病耐药性的实验室基础设施。即使在可用的情况下，当前药物敏感性测试（DST）方法的固有延迟也会导致临床恶化和MDR和XDR-TB的持续传播。确定耐药的临床预测因素可能有助于早期治疗和感染control.Methods的风险分层：我们进行了一项回顾性病例对照研究，在南非的高艾滋病毒流行率设置的MDR（病例），XDR（病例）和药物敏感（对照）结核病患者，以确定耐药结核病的临床和人口统计学危险因素。以1：1：1的比例选择对照，并且不匹配。我们计算比值比（OR），并进行多变量logistic回归，以确定独立predictors.Results：我们招募了116，123和139名患者的药物敏感，耐多药，广泛耐药结核病。在所有三个患者群体中，85%以上的人感染了艾滋病毒。在多变量分析中，MDR和XDR-TB均与TB治疗失败史（校正OR分别为51.7 [CI 6.6-403.7]和51.5 [CI 6.4-414.0]）和住院超过14天（aOR分别为3.8 [CI 1.1-13.3]和6.1 [CI 1.8-21.0]）密切相关。既往未接受结核病治疗不是MDR或XDR-TB的风险因素。HIV是XDR的危险因素（aOR 8.2，CI 1.3-52.6），但不是MDR-TB。将广泛耐药结核患者与耐多药结核患者进行比较，发现广泛耐药结核的唯一显著危险因素是HIV感染（aOR 5.3，CI 1.0-27.6）。讨论：在这种HIV高流行率和耐药结核背景下，长期住院史和既往结核病治疗失败是耐多药结核和广泛耐药结核的强危险因素。鉴于在HIV和耐药结核病合并感染患者中观察到的高死亡率，在MDR/XDR-TB高负荷环境中，应考虑既往接受过治疗和住院的患者进行经验性二线结核病治疗，同时等待确证性DST结果。
Background: Multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) have emerged in high-HIV-prevalence settings, which generally lack laboratory infrastructure for diagnosing TB drug resistance. Even where available, inherent delays with current drug-susceptibility testing (DST) methods result in clinical deterioration and ongoing transmission of MDR and XDR-TB. Identifying clinical predictors of drug resistance may aid in risk stratification for earlier treatment and infection control.Methods: We performed a retrospective case-control study of patients with MDR (cases), XDR (cases) and drug-susceptible (controls) TB in a high-HIV-prevalence setting in South Africa to identify clinical and demographic risk factors for drug-resistant TB. Controls were selected in a 1: 1: 1 ratio and were not matched. We calculated odds ratios (OR) and performed multivariate logistic regression to identify independent predictors.Results: We enrolled 116, 123 and 139 patients with drug-susceptible, MDR, and XDR-TB. More than 85% in all three patient groups were HIV-infected. In multivariate analysis, MDR and XDR-TB were each strongly associated with history of TB treatment failure (adjusted OR 51.7 [CI 6.6-403.7] and 51.5 [CI 6.4-414.0], respectively) and hospitalization more than 14 days (aOR 3.8 [CI 1.1-13.3] and 6.1 [CI 1.8-21.0], respectively). Prior default from TB treatment was not a risk factor for MDR or XDR-TB. HIV was a risk factor for XDR (aOR 8.2, CI 1.3-52.6), but not MDR-TB. Comparing XDR with MDR-TB patients, the only significant risk factor for XDR-TB was HIV infection (aOR 5.3, CI 1.0-27.6).Discussion: In this high-HIV-prevalence and drug-resistant TB setting, a history of prolonged hospitalization and previous TB treatment failure were strong risk factors for both MDR and XDR-TB. Given high mortality observed among patients with HIV and drug-resistant TB co-infection, previously treated and hospitalized patients should be considered for empiric secondline TB therapy while awaiting confirmatory DST results in settings with a high-burden of MDR/XDR-TB.