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Revista Portuguesa de Pneumologia

versão impressa ISSN 0873-2159

Rev Port Pneumol v.13 n.6 Lisboa dez. 2007

 

A tuberculose multirresistente e a rainha vermelha – A rapidez do diagnóstico é decisiva

 

Multi-drug resistant tuberculosis and the red queen – Diagnosis speed is crucial

 

João Costeira 1

Jaime Pina 2

 

 

Resumo

A tuberculose multirresistente é uma ameaça importante ao controlo da tuberculose.

Neste sentido, é fundamental o diagnóstico precoce da TBMR para adoptar as medidas mais adequadas.

Os métodos de detecção da resistência aos antibacilares baseados na avaliação das determinantes genéticas (métodos genotípicos) têm a vantagem, em relação aos métodos clássicos (fenotípicos), de serem mais céleres, poderem ser aplicados directamente na amostra clínica e de identificarem simultaneamente o Mycobacterium tuberculosis complex.

A análise dos dados dos doentes internados no Serviço de Pneumologia 2 do Hospital de Pulido Valente mostrou uma significativa prevalência de TBMR (10,3%). Revelou, também, que em 34,1% dos doentes com TBMR a multirresistência não foi identificada, tendo sido a mortalidade nesses doentes de 31% versus 18,4% nos doentes com o perfil de resistências previamente conhecido. Estes valores são piores nos doentes com TBMR+SIDA, que têm uma mortalidade de 50% versus 15%, respectivamente.

Para uma rápida identificação das resistências nos doentes internados no Serviço de Pneumologia 2 do HPV, foi avaliado o teste INNO-LIPA Rif.TB para detecção da resistência à RMP como marcador de multirresistência.

Os resultados do teste, efectuado em 113 amostras, mostraram elevadas taxas de sensibilidade (91,6%), especificidade (98%), valor preditivo positivo (84,6%) e valor preditivo negativo (99%).

A demora média para obter os resultados foi de 7,6 dias para o teste genotípico versus 23,4 dias para o teste fenotípico (BACTEC MGIT 960).

Actualmente, o teste INNO-LIPA Rif. TB é aplicado em todos os doentes internados com tuberculose bacilífera sem perfil de resistências previamente conhecido, com bons resultados.

Palavras-chave: Tuberculose multirresistente, método genotípico, sensibilidade, especificidade.

 

 

 

Abstract

The multi-drug resistant Tuberculosis (MDRTB) is a huge menace to Tuberculosis control.

The early detection of MDRTB is essential to best appropriate measures.

The detection methods for drug resistance based in evaluation of the genetic determinants (genotypic methods), instead of phenotypic methods, allows for faster results, the possibility of direct application in clinical samples and simultaneous identification of Mycobacterium tuberculosis complex.

The inpatients data analysis in the “Serviço de Pneumologia 2 do Hospital Pulido Valente”, showed a high prevalence of MDRTB (10.3%). In 34.1% of the MDRTB patients the multi-drug resistance was not been identified, with a mortality ratio in this cases of 31% versus 18.4% in the subset of patients with resistance previously identified.

Moreover the mortality ratio was worst in MDRTB/AIDS patients with 50% versus 15%, respectively.

Targeting for rapid drug resistance detection, in hospitalized patients at “Serviço de Pneumologia 2 do Hospital Pulido Valente”, the test INNO-LIPA Rif.TB, to identify the rifampicin resistance as a marker of multi-drug resistance, was evaluated.

The test was performed in 113 samples and had a high ratio of sensitivity (91.6%), specificity (98%), positive predictive value (84, 6%) and negative predictive value (99%).

Time to obtain the results was 7.6 days for the genotypic test versus 23.4 days to the phenotypic test (BACTEC MGIT 960).

The INNO-LIPA Rif.TB test is, now, performed in every patient with smear-positive Tuberculosis with no previous knows resistance profile, with good outcome.

Key-words: Multi-drug resistant tuberculosis, genotypic method, sensitivity, specificity.

 

 

Texto completo disponível apenas em PDF.

Full text only available in PDF format.

 

 

Bibliografia

1. Youmans G P, Williston E H, Feldman W H, Hinshaw H C. Increase in resistance of tubercle bacilli to streptomycin, preliminary report. Mayo Cli 1946; 21: 126-7.        [ Links ]

2. Sungkanuparh S, Eampokalap B, Chottanapund S, Thongyen S, Manosuthi W. Impact of drug-resistant tuberculosis

on the survival of HIV-infected patients. Int J Tuberc Dis 2007; 11 (3): 325-30.

3. Mitchison DA, How drug resistance emerges as a result of poor compliance during short course chemotherapy for tuberculosis. Int J Tuberc. Lung Dis 1998, 2. 10-5.

4. Mitchison DA, Nunn A J. Influence of initial drug resistance on the response to short-course chemotherapy of pulmonary tuberculosis. Am Rev Respir Dis 1986; 133 (3): 423-30.

5. WHO. Treatment of Tuberculosis. Guidelines for national programmes. 3rd edn. WHO/CDS/2003.313. Geneva. World Health Organization. 2003.

6. Frieden TR, Sterling T, Pablos-Mendez A, Kilburn J O, Cauthen G M, Dooley S W. The emergence of drugresistant tuberculosis in New York City. N Engl J Med 1993; 328:521-6.

7. Nosocomial transmission of multi-drug resistant tuberculosis among HIV-infected persons – Florida and New York, 1988-1991. MMWR Morb Mortal Wkly Rep 1991; 40: 585-91.

8. Quy H T, Cobelens F G, Lan N T, Buu T N, Lambregts C S, Borgdorff M W. Treatment outcomes by drug resistance and HIV status among tuberculosis patients in Ho Chi Minh City, Vietnam. Int J Tuberc Lung Dis 2006; 10 (1): 45-51.

9. Chiang CY, Enarson DA, Yu MC, Bai KJ, Huang RM, Hsu CJ, SuoJ, Lin TP. Outcome of pulmonary multidrugresistant tuberculosis: a 6 yr follow-up study. Eur Respir J 2006; 28: 980-5.

10. Sungkanuparh S, Eampokalap B, Chottanapund S, Thongyen S, Manosuthi W. Impact of drug-resistant tuberculosis on the survival of HIV-infected patients. Int J Tuberc Dis 2007; 11 (3): 325-30.

11. World Health Organization, Extensively drug-resistant tuberculosis (XDR-TB): recommendations for prevention and control. Wkly Epidemiol Rec 2006; 81:430-2.

12. Migliori G B, Ortmann J, Girardi E, Besozzi G, Lange C, Cirillo D M, Ferrarese M, Iaco G, Gori A, Raviglione M C, and SMIRA/TBNET Study Group, Extensively Drug-resistant Tuberculosis, Italy and Germany, CDC Emerging Infectious Diseases 2007; 13:780-2.

13. Sharma SK., Mohan A., Multidrug-Resistant Tuberculosis A Menace That Threatens To Destabilize Tuberculosis Control, Chest 2006; 130:261-72.

14. Migliori G B, Loddenkemper R, Blasi F, Raviglione M C. 125 years after Robert Koch’s discovery of the tubercule bacillus: the new XDR-TB threat. Is “science” enough to tackle the epidemic? Eur Respir J 2007; 29:423-7.

15. Gandhi N R, Moll A, Sturn A W, Pawinski R, Govender T, Lallo U, Zeller K, Andrews J, Friendland G. 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; 368:1575-80.

16. Nahid P., Pai M., Hopewell P., Advances in the Diagnosis and Treatment of Tuberculosis, Proc Am Thorax Soc 2006; 3:103-10.

17. Tortoli E, Palomino JC, Chapter 14 New Diagnostic Methods, Tuberculosis 2007 TuberculosisTextbook.com, First Edition, 441-86.

18. Anandi Martin and Françoise Portaels; Chapter 19: Drug Resistance and Drug Resistance Detection, Tuberculosis 2007 TuberculosisTextbook.com. First Edition, 635-60.

19. Traore, H., Deun A, Shamputa I C, Rigouts L, Portaels F. Direct Detection of Mycobacterium tuberculosis Complex DNA and Rifampin Resistance in Clinical Specimens from Tuberculosis Patients by Line Probe Assay, Journal of Clinical Microbiology 2006; 44:4384-8.

20. Viveiros M., Leandro C., Rodrigues L., Almeida J, Bettencourt R, Couto I, et al. Direct Application of the INNO-LIPA Rif.TB Line-Probe Assay for Rapid Identification of Mycobacterium tuberculosis Complex Strains and Detection Resistance in 360 Smear-Positive Respiratory Specimens from an Area of High Incidence of Multidrug-Resistant Tuberculosis, Journal of Clinical Microbiology 2005; 43:4880-4.

21. Morgan M., Kalantri S, Flores L, Pai M. A commercial line probe assay for the rapid detection of rifampicin resistance in Mycobacterium tuberculosis: a systematic review and meta-analysis, BMC infectious Diseases 2005; 5:62.

22. Viveiros M, Leandro C, Rodrigues L, Almeida J, Bettencourt R, Couto I, et al. Diagnóstico da Tuberculose O Programa “Faster-Track” de Combate à Tuberculose Multirresistente na Grande Lisboa, Tuberculose-Impacto da Infecção pelo VIH 12.ª Reunião de Pneumologistas do Hospital Pulido Valente 2005; 83-99.

23. Kaufmann SHE, Cole ST, Mizrahi V, Rubin E, Nathan C. Mycobacterium tuberculosis and the host response. J Exp Med 2005; 6:1963-7.

24. Schluger N W. The Pathogenesis of Tuberculosis, The First One Hundred (and Twenty-Three) Years, Am J Respir Cell Mol Biol 2005; 32:251-6.

25. Van Valen L. A new evolutionary law. Evolutionary Theory 1973; 1:1-30.

26. Carrol L. 1872. Through the looking glass and what Alice found there. MacMillan, London.

 

 

1 Assistente Hospitalar Graduado de Pneumologia

João.Costeira@hpv.min-saude.pt

2 Chefe de Serviço Hospitalar de Pneumologia e Director do Serviço de Pneumologia 2 do Hospital de Pulido Valente, Lisboa

Hospital de Pulido Valente, EPE

Alameda das Linhas de Torres

117 1769-001 Lisboa

 

Recebido para publicação/received for publication: 07.07.02

Aceite para publicação/accepted for publication: 07.09.12