203例老年肺结核合并2型糖尿病患者耐药状况及影响因素分析

doi:10.19983/j.issn.2096-8493.2024004

摘要/Abstract

摘要：

目的: 分析老年肺结核合并2型糖尿病患者耐药特征及影响因素。方法: 采用回顾性研究方法,收集2021年1月1日至2022年12月31日成都市公共卫生临床医疗中心收治的痰培养阳性且菌种鉴定为结核分枝杆菌的203例老年肺结核合并2型糖尿病患者的药物敏感性试验结果及相关临床资料,采用单因素和多因素logistic回归模型分析其耐药特征及发生耐药的影响因素。结果: 203例老年肺结核合并糖尿病患者的总耐药率为40.4%(82/203),单耐药率为12.3%(25/203),多耐药率为4.9%(10/203),耐多药率为12.8%(26/203)。14种抗结核药物的总耐药率由高至低前3位依次为异烟肼(INH)[22.7%(46/203)]>利福平(RFP)[15.8%(32/203)]>链霉素(Sm)[14.8%(30/203)],且对莫西沙星(Mfx)[11.3%(23/203)]和左氧氟沙星(Lfx)[10.8%(22/203)]的耐药率均较高。多因素logistic回归模型分析显示,复治、低蛋白血症和CD4⁺T淋巴细胞绝对计数<414个/μl均是老年肺结核合并糖尿病患者发生耐药的独立危险因素(OR=4.528,95%CI:2.031~10.099,P<0.001;OR=2.106,95%CI:1.116~3.972,P=0.021;OR=1.887,95%CI:1.011~3.532,P=0.046)。结论: 老年肺结核合并糖尿病患者耐药率较高,且以一线抗结核药物耐药为主,应积极开展耐药筛查,并对复治、有低蛋白血症和CD4⁺T淋巴细胞绝对计数<414个/μl的患者尽早采取防治措施。

关键词: 结核,肺, 糖尿病, 共病现象, 药物耐受性, 老年人, 因素分析, 统计学

Abstract:

Objective: To explore the characteristics and the related influencing factors of drug resistance in aged pulmonary tuberculosis patients combined with type 2 diabetes. Methods: A retrospective study was conducted to collect the drug sensitivity test results and clinical data of 203 aged pulmonary tuberculosis patients combined with type 2 diabetes who were admitted to Public Health Clinical Center of Chengdu from January 1, 2021 to December 31, 2022 and identified as Mycobacterium tuberculosis with positive sputum culture. The characteristics of drug resistance and the influencing factors of drug resistance were analyzed by univariate and multivariate logistic regression models. Results: In 203 aged pulmonary tuberculosis patients combined with type 2 diabetes, the total drug resistance rate of was 40.4% (82/203), the rate of single drug resistance was 12.3% (25/203), the rate of poly-resistant tuberculosis was 4.9% (10/203) and the rate of multi-drug resistant tuberculosis was 12.8% (26/203). The top three drug resistance rates of 14 anti-tuberculosis drugs were INH (22.7% (46/203))>RFP (15.8% (32/203))>Sm (14.8% (30/203)), and the drug resistance rates of Mfx (11.3% (23/203)) and Lfx (10.8% (22/203)) were higher. Multivariate logistic regression analysis showed that retreatment (OR=4.528, 95%CI: 2.031-10.099, P<0.001), hypoproteinemia (OR=2.106, 95%CI: 1.116-3.972, P=0.021) and CD4⁺T lymphocyte count <414 cell/μl (OR=1.887, 95%CI: 1.011-3.532, P=0.046) were independent risk factors for drug resistance in aged pulmonary tuberculosis patients combined with type 2 diabetes. Conclusion: The drug resistance rate of aged pulmonary tuberculosis patients combined with type 2 diabetes is high, and the drug resistance is mainly caused by first-line anti-tuberculosis drugs. Drug resistance screening should be actively carried out, and prevention and control measures should be taken as soon as possible for patients with retreatment, hypoproteinemia and CD4⁺T lymphocyte count <414 cell/μl.

Key words: Tuberculosis, pulmonary, Diabetes mellitus, Comorbidity, Drug tolerance, Aged, Factor analysis, statistical

中图分类号:

倪楠, 陈晴, 唐先珍, 邹莉萍, 梁丽, 吴桂辉, 毛俐. 203例老年肺结核合并2型糖尿病患者耐药状况及影响因素分析[J]. 结核与肺部疾病杂志, 2024, 5(1): 28-36. doi: 10.19983/j.issn.2096-8493.2024004

Ni Nan, Chen Qing, Tang Xianzhen, Zou Liping, Liang Li, Wu Guihui, Mao Li. Analysis of drug resistance status and influencing factors in 203 aged patients with pulmonary tuberculosis combined with type 2 diabetes[J]. Journal of Tuberculosis and Lung Disease, 2024, 5(1): 28-36. doi: 10.19983/j.issn.2096-8493.2024004

图/表 5

表1

表2

不同耐药类型在老年合并糖尿病患者中的初、复治分布情况

耐药类型	初治(167例)	复治(36例)	合计(203例)	χ²值	P值
总耐药	57(34.1)	25(69.4)	82(40.4)	15.338	<0.001
任一耐药
RFP	15(9.0)	17(47.2)	32(15.8)	32.614	<0.001
INH	27(16.2)	19(52.8)	46(22.7)	22.650	<0.001
Sm	20(12.0)	10(27.8)	30(14.8)	5.872	0.015
EMB	1(0.6)	5(13.9)	6(3.0)	-	0.001
Rfb	9(5.4)	7(19.4)	16(7.9)	8.058	0.011
Pto	0(0.0)	1(2.8)	1(0.5)	-	0.177
PAS	7(4.2)	1(2.8)	8(3.9)	-	1.000
Am	2(1.2)	1(2.8)	3(1.5)	-	0.445
Cm	5(3.0)	2(5.6)	7(3.4)	-	0.610
Km	5(3.0)	1(2.8)	6(3.0)	-	1.000
Mfx	16(9.6)	7(19.4)	23(11.3)	2.868	0.141
Lfx	15(9.0)	7(19.4)	22(10.8)	3.355	0.067
Cfz	0(0.0)	1(2.8)	1(0.5)	-	0.177
Rft	12(7.2)	11(30.6)	23(11.3)	16.100	<0.001
单耐药	21(12.6)	4(11.1)	25(12.3)	-	1.000
INH	8(4.8)	2(5.6)	10(4.9)	-	0.681
Sm	8(4.8)	1(2.8)	9(4.4)	-	1.000
RFP	2(1.2)	0(0.0)	2(1.0)	-	1.000
RFP+Rfb+Rft^a	1(0.6)	1(2.8)	2(1.0)	-	0.324
RFP+Rft^a	2(1.2)	0(0.0)	2(1.0)	-	1.000
多耐药	7(4.2)	2(5.6)	10(4.9)	-	0.622
INH+Cm	1(0.6)	0(0.0)	1(0.5)	-	0.177
INH+Sm	3(1.8)	2(5.6)	5(2.5)	-	0.216
INH+PAS+Cfz+Lfx+Km	1(0.6)	0(0.0)	1(0.5)	-	0.177
INH+Sm+Cm+PAS+Am	1(0.6)	0(0.0)	1(0.5)	-	0.177
INH+Km+Cm+PAS+Am	1(0.6)	0(0.0)	1(0.5)	-	0.177
INH+Cm+EMB	1(0.6)	0(0.0)	1(0.5)	-	0.177
耐多药(含广泛耐药)	11(6.6)	15(41.7)	26(12.8)	32.635	<0.001
RFP+INH	1(0.6)	2(5.6)	3(1.5)	-	0.082
RFP+INH+Sm	0(0.0)	1(2.8)	1(0.5)	-	0.177
RFP+INH+Sm+Rfb+Rft	2(1.2)	0(0.0)	2(1.0)	-	1.000
RFP+INH+Sm+Rfb+Rft	2(1.2)	1(2.7)	3(1.5)	-	0.445
RFP+INH+Sm+EMB	0(0.0)	1(2.7)	1(0.5)	-	0.177
RFP+INH+Sm+PAS+Rft	1(0.6)	0(0.0)	1(0.5)	-	0.177
RFP+INH+Sm+PAS+Rft+Rfb	1(0.6)	0(0.0)	1(0.5)	-	0.177
RFP+INH+Sm+Rft+Cfz+Rfb+Km	0(0.0)	1(2.8)	1(0.5)	-	0.177
RFP+INH+EMB+PAS+Rft	0(0.0)	1(2.8)	1(0.5)	-	0.177
RFP+INH+Rfb+Rft	2(1.2)	1(2.8)	3(1.5)	-	0.445
RFP+INH+Rft	0(0.0)	1(2.8)	1(0.5)	-	0.177
RFP+INH+Sm+EMB+Lfx+Mfx+Rft	0(0.0)	1(2.8)	1(0.5)	-	0.177
RFP+INH+Sm+EMB+Lfx+Mfx+Pto	0(0.0)	1(2.8)	1(0.5)	-	0.177
RFP+INH+Sm+PAS+Rft+Lfx+Mfx+Rfb	1(0.6)	0(0.0)	1(0.5)	-	0.177
RFP+INH+Sm+Rft+Lfx+Mfx+Rfb	1(0.6)	1(2.8)	2(1.0)	-	0.324
RFP+INH+EMB+Lfx+Mfx+Rft	0(0.0)	1(2.8)	1(0.5)	-	0.177
RFP+INH+Lfx+Mfx+Rfb+Rft	0(0.0)	1(2.8)	1(0.5)	-	0.177
RFP+INH+Cm+Am	0(0.0)	1(2.8)	1(0.5)	-	0.177

表2

表3

表4

表5

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临床特征	患者例数	构成比(%)	临床特征	患者例数	构成比(%)
性别			≤10	164	80.8
男性	154	75.9	糖尿病病程(年)
女性	49	24.1	≥5	89	43.8
居住地			<5	114	56.2
城市	113	55.7	降糖治疗
农村	90	44.3	是	67	33.0
初复治类型			否	136	67.0
初治	167	82.3	贫血
复治	36	17.7	是	98	48.3
耐药			否	105	51.7
是	82	40.4	营养不良
全敏感	121	59.6	是	41	20.2
肺空洞			否	162	79.8
有	161	79.3	糖尿病肾病
无	42	20.7	有	44	21.7
低蛋白血症(g/L)			无	159	78.3
≥35	76	37.4	糖尿病血管病变
<35	127	62.6	有	38	18.7
糖化血红蛋白(%)			无	165	81.3
>8.5	116	57.1	糖尿病周围神经病
≤8.5	87	42.9	有	22	10.8
CD4⁺T淋巴细胞(个/μl)			无	181	89.2
≥414	81	39.9	糖尿病眼部并发症
<414	122	60.1	有	10	4.9
空腹血糖(mmol/L)			无	193	95.1
>10	39	19.2

影响因素	耐药组(82例)		敏感组(121例)		χ²值	P值
影响因素	例数	构成比(%)	例数	构成比(%)	χ²值	P值
性别					1.608	0.205
男性	66	80.5	88	72.7
女性	16	19.5	33	27.3
居住地					0.460	0.498
城市	48	58.5	65	53.7
农村	34	41.5	56	46.3
初复治类型					15.339	<0.001
初治	57	69.5	110	90.9
复治	25	30.5	11	9.1
肺空洞					0.482	0.488
有	67	81.7	94	77.7
无	15	18.3	27	22.3
低蛋白血症(g/L)					6.611	0.010
≥35	22	26.8	54	44.6
<35	60	73.2	67	55.4
糖化血红蛋白(%)					0.682	0.409
>8.5	44	53.7	72	59.5
≤8.5	38	46.3	49	40.5
CD4⁺T淋巴细胞(个/μl)					3.852	0.050
≥414	26	31.7	55	45.5
<414	56	68.3	66	54.5
空腹血糖(mmol/L)					0.665	0.415
>10	18	22.0	21	17.4
≤10	64	78.0	100	82.6
糖尿病病程(年)					2.037	0.154
≥5	31	37.8	58	47.9
<5	51	62.2	63	52.1
降糖治疗					0.347	0.556
是	29	35.4	38	31.4
否	53	64.6	83	68.6
贫血					0.140	0.906
是	40	48.8	58	47.9
否	42	51.2	63	52.1
营养不良					0.755	0.385
是	19	23.2	22	18.2
否	63	76.8	99	81.8
糖尿病肾病					0.006	0.937
有	18	22.0	26	21.5
无	64	78.0	95	78.5
糖尿病血管病变					2.544	0.111
有	11	13.4	27	22.3
无	71	86.6	94	77.7
糖尿病周围神经病					0.754	0.385
有	7	8.5	15	12.4
无	75	91.5	106	87.6
糖尿病眼部并发症					0.472	0.492
有	3	3.7	7	5.8
无	79	96.3	114	94.2

变量	赋值
因变量
药敏试验结果	全敏感=0;耐药=1
自变量
初复治类型	初治=0;复治=1
低白蛋白血症	≥35g/L=0;<35g/L=1
外周血CD4⁺T淋巴细胞绝对计数	≥414个/μl=0;<414个/μl=1

影响因素	β值	s$ \bar{x}$值	Wald χ²值	P值	OR(95%CI)值
CD4⁺T淋巴细胞绝对计数<414个/μl	0.635	0.318	3.977	0.046	1.887(1.011~3.532)
低蛋白血症	0.745	0.324	5.289	0.021	2.106(1.116~3.972)
复治	1.510	0.409	13.622	<0.001	4.528(2.031~10.099)