UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

广泛耐药结核病的流行病学

Authors
Scott K Heysell, MD, MPH
Gerald Friedland, MD
Section Editor
C Fordham von Reyn, MD
Deputy Editor
Elinor L Baron, MD, DTMH
Translators
郭述良, 主任医师

引言

结核分枝杆菌(Mycobacterium tuberculosis)是一种古老的人类病原体，尽管在上个世纪已引入了治愈性和预防性的治疗，但这一病原体仍困扰着无数的人类社会。近年来，国际注意力已转向于不断进展的耐药负担。在世界上最贫穷的人群中(包括撒哈拉以南非洲)，随着广泛HIV感染流行，多重耐药结核病(multidrug-resistant tuberculosis, MDR-TB)已呈流行程度。广泛耐药结核病(extensively drug-resistant tuberculosis, XDR-TB)最先报道于2006年，但现在六大洲均已有病例记录[1]。这些趋势对于全球卫生是至关重要的，因为耐药性结核病的死亡率很高，并且二线药物和三线药物治疗耐药性结核病的效力和耐受性也不如一线治疗。

本专题将特别关注XDR-TB的流行病学和临床特征。关于MDR-TB、药物敏感性结核病和结核病诊断的信息将在别处详细讨论。 (参见“肺结核的临床表现和评估”和“Epidemiology, clinical manifestations, and diagnosis of tuberculosis in HIV-infected patients”和“耐药结核病的诊断、治疗及预防”)

定义

MDR-TB的定义是：实验室证实对异烟肼和利福平(两种最强效的一线药物)具有耐药性[2]。自2007年起，XDR-TB被定义为对异烟肼和利福平均具耐药性，且还至少对1种氟喹诺酮类药物和1种注射药物(阿米卡星、卡那霉素或卷曲霉素)具有耐药性[3,4]。

对当地测试的所有药物都耐药的结核分枝杆菌菌株被定义为“完全耐药”(totally drug-resistant, TDR)-TB[5,6]。然而，并未检测这些TDR分离株对所有二线抗结核药物的耐药性，包括环丝氨酸、特立齐酮、氯法齐明、利奈唑胺、碳青霉烯类药物以及新药贝达喹啉和迪拉马尼。不管怎样，TDR-TB报道引起了关于在资源有限情况下追踪复杂耐药性模式能力的流行病学担忧[7]。TDR-TB的出现也强调了：不常用的抗结核药物的药敏试验的可用性有限；对弱效药物联合会引起耐药性放大的担心；相对不能预测感染部位药物的活性或药物的协同作用；对最优化药物代谢动力学策略和全新的抗结核药物方案的需求。

XDR-TB耐药性的估计

首次发现耐药性是在20世纪40年代，当时链霉素正式被研究作为单药治疗用于结核病治疗[8]。因此，随后的治疗干预使用了多药方案以降低发生耐药性的风险。

              

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2017-01-25.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. World Health Organization. The WHO Global Laboratory Initiative. http://www.who.int/tb/dots/laboratory/gli/en/index.html (Accessed on March 01, 2009).
  2. Frieden TR, Fujiwara PI, Washko RM, Hamburg MA. Tuberculosis in New York City--turning the tide. N Engl J Med 1995; 333:229.
  3. Report WHO/HTM/TB/2006.375 (World Health Organization, Geneva, 2006).
  4. Centers for Disease Control and Prevention. Revised definition of extensively drug-resistant tuberculosis. MMWR Morbid Mortal Wkly Rep 2006; 55:1176.
  5. Velayati AA, Masjedi MR, Farnia P, et al. Emergence of new forms of totally drug-resistant tuberculosis bacilli: super extensively drug-resistant tuberculosis or totally drug-resistant strains in iran. Chest 2009; 136:420.
  6. Udwadia ZF, Amale RA, Ajbani KK, Rodrigues C. Totally drug-resistant tuberculosis in India. Clin Infect Dis 2012; 54:579.
  7. Shah NS, Richardson J, Moodley P, et al. Increasing drug resistance in extensively drug-resistant tuberculosis, South Africa. Emerg Infect Dis 2011; 17:510.
  8. STREPTOMYCIN treatment of pulmonary tuberculosis. Br Med J 1948; 2:769.
  9. Centers for Disease Control and Prevention (CDC). Multidrug-resistant tuberculosis outbreak on an HIV ward--Madrid, Spain, 1991-1995. MMWR Morb Mortal Wkly Rep 1996; 45:330.
  10. Ritacco V, Di Lonardo M, Reniero A, et al. Nosocomial spread of human immunodeficiency virus-related multidrug-resistant tuberculosis in Buenos Aires. J Infect Dis 1997; 176:637.
  11. Moro ML, Gori A, Errante I, et al. An outbreak of multidrug-resistant tuberculosis involving HIV-infected patients of two hospitals in Milan, Italy. Italian Multidrug-Resistant Tuberculosis Outbreak Study Group. AIDS 1998; 12:1095.
  12. From the Centers for Disease Control and Prevention. Tuberculosis treatment interruptions--Ivanovo Oblast, Russian Federation, 1999. JAMA 2001; 285:1953.
  13. Selwyn PA, Hartel D, Lewis VA, et al. A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection. N Engl J Med 1989; 320:545.
  14. Raviglione MC, Harries AD, Msiska R, et al. Tuberculosis and HIV: current status in Africa. AIDS 1997; 11 Suppl B:S115.
  15. World Health Organization. Drug-Resistant TB Surveillance and Response: Supplement Global Tuberculosis Report 2014. WHO, Geneva 2014.
  16. Gandhi NR, Moll A, Sturm AW, et al. Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet 2006; 368:1575.
  17. Moll, AP, Gandhi, N. Personal communication.
  18. Moll, AP, Gandhi, N, Andrews, J, et al. Extensively Drug-Resistant (XDR) TB More Common than MDR TB in Tugela Ferry, South Africa with Evidence for Resistance Amplification Over Time. International Union Against Tuberculosis and Lung Disease, 38th, Cape Town, 2007.
  19. Gandhi NR, Shah NS, Andrews JR, et al. HIV coinfection in multidrug- and extensively drug-resistant tuberculosis results in high early mortality. Am J Respir Crit Care Med 2010; 181:80.
  20. Gandhi NR, Weissman D, Moodley P, et al. Nosocomial transmission of extensively drug-resistant tuberculosis in a rural hospital in South Africa. J Infect Dis 2013; 207:9.
  21. Friedland G, Moll AP, Shenoi SV, et al. Extensively and multidrug resistant tuberculosis (XDR/MDR TB) in Tugela Ferry, South Africa; Five years later. Oral Late Breaker. International Union Against TB and Lung Disease, Kuala Lumpur, Malaysia, November 2012
  22. Report WHO/HTM/TB/2008.394. (World Health Organization. Antituberculosis drug resistance in the world, Report No.4, 2008).
  23. Centers for Disease Control and Prevention (CDC). Emergence of Mycobacterium tuberculosis with extensive resistance to second-line drugs--worldwide, 2000-2004. MMWR Morb Mortal Wkly Rep 2006; 55:301.
  24. Shah NS, Wright A, Bai GH, et al. Worldwide emergence of extensively drug-resistant tuberculosis. Emerg Infect Dis 2007; 13:380.
  25. Raviglione MC. Facing extensively drug-resistant tuberculosis--a hope and a challenge. N Engl J Med 2008; 359:636.
  26. WHO. Global tuberculosis report 2012. Geneva, Switzerland: World Health Organization, 2012.
  27. World Health Organization. Global Tuberculosis Report 2014. WHO, Geneva 2014.
  28. Centers for Disease Control and Prevention. Reported Tuberculosis in the United States, 2013. US Department of Health and Human Services, Atlanta, GA 2013. http://www.cdc.gov/tb/statistics/reports/2013/pdf/report2013.pdf (Accessed on May 04, 2015).
  29. Shah NS, Pratt R, Armstrong L, et al. Extensively drug-resistant tuberculosis in the United States, 1993-2007. JAMA 2008; 300:2153.
  30. Sonnenberg P, Murray J, Glynn JR, et al. HIV-1 and recurrence, relapse, and reinfection of tuberculosis after cure: a cohort study in South African mineworkers. Lancet 2001; 358:1687.
  31. Andrews JR, Gandhi NR, Moodley P, et al. Exogenous reinfection as a cause of multidrug-resistant and extensively drug-resistant tuberculosis in rural South Africa. J Infect Dis 2008; 198:1582.
  32. Cox HS, Sibilia K, Feuerriegel S, et al. Emergence of extensive drug resistance during treatment for multidrug-resistant tuberculosis. N Engl J Med 2008; 359:2398.
  33. Cegielski JP, Dalton T, Yagui M, et al. Extensive drug resistance acquired during treatment of multidrug-resistant tuberculosis. Clin Infect Dis 2014; 59:1049.
  34. Zhao Y, Xu S, Wang L, et al. National survey of drug-resistant tuberculosis in China. N Engl J Med 2012; 366:2161.
  35. Isaakidis P, Das M, Kumar AM, et al. Alarming levels of drug-resistant tuberculosis in HIV-infected patients in metropolitan Mumbai, India. PLoS One 2014; 9:e110461.
  36. Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response. WHO/HTM/TB/2010.3
  37. Daftary A, Padayatchi N, O'Donnell M. Preferential adherence to antiretroviral therapy over tuberculosis treatment: a qualitative study of drug-resistant TB/HIV co-infected patients in South Africa. Glob Public Health 2014; 9:1107.
  38. Raykhert I, Miskinis K, Lepshyna S, et al. HIV seroprevalence among new TB patients in the civilian and prisoner populations of Donetsk Oblast, Ukraine. Scand J Infect Dis 2008; 40:655.
  39. Jeon CY, Hwang SH, Min JH, et al. Extensively drug-resistant tuberculosis in South Korea: risk factors and treatment outcomes among patients at a tertiary referral hospital. Clin Infect Dis 2008; 46:42.
  40. Banerjee R, Allen J, Westenhouse J, et al. Extensively drug-resistant tuberculosis in california, 1993-2006. Clin Infect Dis 2008; 47:450.
  41. Friedland G. Tuberculosis, drug resistance, and HIV/AIDS: a triple threat. Curr Infect Dis Rep 2007; 9:252.
  42. Shenoi S, Friedland G. Extensively drug-resistant tuberculosis: a new face to an old pathogen. Annu Rev Med 2009; 60:307.
  43. Galgalo T, Dalal S, Cain KP, et al. Tuberculosis risk among staff of a large public hospital in Kenya. Int J Tuberc Lung Dis 2008; 12:949.
  44. Naidoo S, Jinabhai CC. TB in health care workers in KwaZulu-Natal, South Africa. Int J Tuberc Lung Dis 2006; 10:676.
  45. O'Donnell MR, Jarand J, Loveday M, et al. High incidence of hospital admissions with multidrug-resistant and extensively drug-resistant tuberculosis among South African health care workers. Ann Intern Med 2010; 153:516.
  46. Dubrovina I, Miskinis K, Lyepshina S, et al. Drug-resistant tuberculosis and HIV in Ukraine: a threatening convergence of two epidemics? Int J Tuberc Lung Dis 2008; 12:756.
  47. Barnard M, Albert H, Coetzee G, et al. Rapid molecular screening for multidrug-resistant tuberculosis in a high-volume public health laboratory in South Africa. Am J Respir Crit Care Med 2008; 177:787.
  48. Tortoli E, Marcelli F. Use of the INNO LiPA Rif.TB for detection of Mycobacterium tuberculosis DNA directly in clinical specimens and for simultaneous determination of rifampin susceptibility. Eur J Clin Microbiol Infect Dis 2007; 26:51.