本文選題：耐多藥結(jié)核病　切入點(diǎn)：危險(xiǎn)因素　出處：《南京醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：背景:痰陰轉(zhuǎn)在耐多藥結(jié)核病患者的監(jiān)測(cè)中發(fā)揮重要作用,患者治療隨訪過程中的痰菌改變是預(yù)測(cè)治療轉(zhuǎn)歸的重要指標(biāo)。定期的痰培養(yǎng)的監(jiān)測(cè)對(duì)于早期發(fā)現(xiàn)治療失敗的耐多藥結(jié)核病患者至關(guān)重要。目前有關(guān)痰陰轉(zhuǎn)與普通結(jié)核治療結(jié)局的研究有很多,但很少有隊(duì)列研究調(diào)查耐多藥結(jié)核病患者治療結(jié)局和痰培養(yǎng)陰轉(zhuǎn)之間的關(guān)系以及不同治療時(shí)間后痰培養(yǎng)的陰轉(zhuǎn)對(duì)耐多藥結(jié)核病患者治療結(jié)局的預(yù)測(cè)效率。在中國或印度等結(jié)核病高負(fù)擔(dān)地區(qū)也沒有進(jìn)行過類似的研究。此外耐多藥結(jié)核痰培養(yǎng)陰轉(zhuǎn)的影響因素相關(guān)研究也很少,迄今為止在國內(nèi)還沒類似的研究。方法:2011年12月-2014年3月在江蘇省的四個(gè)地級(jí)市(徐州、連云港、鎮(zhèn)江和南通市)連續(xù)納入確診的耐多藥結(jié)核病患者作為研究對(duì)象。耐多藥結(jié)核病患者在當(dāng)?shù)氐氖屑?jí)定點(diǎn)醫(yī)院結(jié)核病參比實(shí)驗(yàn)室通過傳統(tǒng)藥敏實(shí)驗(yàn)確診。納入到研究中的耐多藥患者都將簽署患者知情同意書,隨后當(dāng)?shù)卣{(diào)查員將會(huì)對(duì)患者進(jìn)行問卷調(diào)查并收集患者的人口學(xué)和治療相關(guān)信息。耐多藥患者根據(jù)藥敏結(jié)果及用藥史采用標(biāo)準(zhǔn)治療方案或個(gè)體治療方案,并定期對(duì)病人進(jìn)行痰培養(yǎng)檢查,注射期每月1次,非注射期每?jī)蓚�(gè)月1次。計(jì)算2月、3月、6月和24月末的痰培養(yǎng)的陰轉(zhuǎn)率,采用Cox比例風(fēng)險(xiǎn)模型探討痰菌陰轉(zhuǎn)時(shí)間對(duì)耐多藥結(jié)核病患者治療結(jié)局的影響。結(jié)果:研究共納入139名有治療結(jié)局的耐多藥結(jié)核病患者。其中106(76.3%)人的痰培養(yǎng)發(fā)生陰轉(zhuǎn),中位陰轉(zhuǎn)時(shí)間是91.5天(四分位數(shù)間距:34.0天-111.8天)。84(60.4%)名患者治療成功,55(39,6%)名患者治療失敗或死亡。治療成功病人的痰培養(yǎng)中位陰轉(zhuǎn)時(shí)間是92.0天(95%CI:85.5-98.5天),低于(χ2 =26.05,P0.001)治療失敗或死亡病人的痰培養(yǎng)陰轉(zhuǎn)時(shí)間174天(95%CI:0-513天)。2月末痰培養(yǎng)陰轉(zhuǎn)與治療結(jié)局之間關(guān)聯(lián)無統(tǒng)計(jì)學(xué)意義(HR=2.0;95%CI=0.9-4.5;P=0.087)。然而3月末(HR=2.7;95%CI=1.3-5.5;P=0.007)、6月末(HR=12.3;95%CI=5.0-30.3;P0.001)以及24月末(HR=22.3;95%CI=7.2-69.4;P0.001)痰培養(yǎng)陰轉(zhuǎn)的患者的治愈率大大增加。2月、3月、6月和24月末的靈敏度分別為33.3%、52.4%、90.5%和95.2%,特異度分別為80.0%,70.9%,56.4%和52.7%。經(jīng)多因素分析結(jié)果顯示,吸煙(HR=0.44;95%CI:0.23-0.83;P=0.011)、飲酒(HR=0.41;95%CI:0.21-0.81;P=0.011)、氧氟沙星耐藥(HR=0.43;95%CI:0.24-0.76;P=0.003)以及初始涂片等級(jí)1(HR=0.51;95%CI:0.31-0.83;P=0.008)為耐多藥結(jié)核病患者痰培養(yǎng)陰轉(zhuǎn)的影響因素。結(jié)論:與2月末及3月末痰培養(yǎng)陰轉(zhuǎn)相比,6月末的痰培養(yǎng)陰轉(zhuǎn)更適合預(yù)測(cè)MDR-TB患者的治療結(jié)局。吸煙、飲酒、有氧氟沙星耐藥及高涂片等級(jí)影響耐多藥結(jié)核患者的痰培養(yǎng)陰轉(zhuǎn),應(yīng)提高重視。
[Abstract]:Background: phlegm-negative conversion plays an important role in the monitoring of MDR-TB patients. The change of sputum bacteria during follow-up is an important index to predict the outcome of treatment. Regular monitoring of sputum culture is very important for early detection of MDR-TB patients who fail in treatment. There are a lot of studies on the outcome of TB treatment. However, few cohort studies have investigated the relationship between treatment outcome and sputum culture negativity in MDR-TB patients and the predictive effectiveness of sputum culture negative-conversion in MDR-TB patients after different treatment periods. No similar studies have been carried out in high-burden areas such as India. In addition, few studies have been conducted on the factors affecting the negative sputum culture of MDR-TB. Methods: from December 2011 to March 2014, there are four prefecture-level cities in Jiangsu Province (Xuzhou, Lianyungang). Zhenjiang and Nantong)) continuous inclusion of confirmed MDR-TB patients as research objects. MDR-TB patients were confirmed by traditional drug-sensitivity tests in the tuberculosis reference laboratory of the local designated hospitals at the municipal level. All patients who are investigated for multi-drug resistance will sign the informed consent form of the patient. Local investigators will then conduct questionnaires on patients and collect demographic and treatment-related information. Multidrug resistant patients will adopt standard or individual treatment programs based on drug sensitivity results and drug history. Sputum culture was examined regularly, once a month for injection period and once every two months for non-injection period. The negative rate of sputum culture was calculated at the end of 2 months, 3 months, 6 months and 24 months. Cox proportional risk model was used to investigate the effect of sputum negative transition time on the outcome of treatment in patients with MDR-TB. Results: one hundred and nine patients with MDR-TB with therapeutic outcome were enrolled in the study. The sputum culture turned negative in 106 patients with MDR-TB. The median negative conversion time was 91.5 days (quartile interval: 34.0 days -111.8 days and 84,60.4 days). The median negative conversion time of sputum culture in successful patients was 92.0 days, 95.5-98.5 days, which was lower than that of successful patients (蠂 2 / 26.05 / P 0.001). The sputum culture negative conversion time of dead patients was 174 days and 95CI: 0-513 days. There was no significant correlation between sputum culture negativity and the outcome of treatment at the end of February. 2. There was no statistical significance. However, at the end of March, HR2.795 CII 1.3-5.5P0.007CII 1.3-5.5P0.007CII and HR12.395CII 5.0-30.3CII at the end of 24 months had a great cure rate. At the end of 24 months, the patients with negative sputum culture were 22.395 CI 7.2-69.4P0.001). The sensitivities at the end of February, March, June and the end of 24 were 90.5% and 95.2%, respectively, and the specificity were 80.0% and 70.9%, 56.4% and 52.7%, respectively. Smoking and initial smear grade 1HR0.551% 0.31-0.83P0.008) are the influencing factors of sputum conversion in patients with MDR-TB. Conclusion: sputum culture negative turn in late February and the end of March compared with sputum negative conversion in late February and end of March, ofloxacin resistance HR0.4395 CIW 0.24-0.76 P0.003) and initial smear grade 1HR0.551 / 95CI0.31-0.83P0.008) are the influencing factors of sputum conversion in patients with multidrug-resistant tuberculosis (MDR-TB). Conclusion: compared with the sputum culture in late February and the end of March, the sputum culture turns negative to negative in patients with multidrug resistance. Suitable for predicting the outcome of treatment in patients with MDR-TB. Drinking, ofloxacin resistance and high smear grade influence the sputum culture negativity of MDR-TB patients, and should be paid more attention to.
【學(xué)位授予單位】：南京醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R52

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