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Revista Portuguesa de Pneumologia

Print version ISSN 0873-2159

Rev Port Pneumol vol.14 no.6 Lisboa Dec. 2008

 

Análise comparativa entre tuberculose multirresistente e tuberculose extensivamente resistente – Epidemiologia e factores preditivos

 

Ana Sofia Vilariça1

Carlos Gomes2

Jaime Pina3

 

Resumo

Introdução: A tuberculose extensivamente resistente (TBXDR) define -se como uma forma de tuberculose multirresistente (TBMR) com resistências adicionais às fluoroquinolonas e, pelo menos, a um dos antibacilares injectáveis seguintes: amicacina, canamicina e capreomicina. Foi classificada pela OMS como uma ameaça séria ao controlo da tuberculose, com consequências à escala mundial, assumindo os contornos de uma autêntica pandemia em algumas regiões do globo.

Objectivo: Comparar os doentes com TBXDR versus outros perfis de TBMR no que diz respeito às características demográficas e epidemiológicas, factores etiopatogénicos e evolução no internamento.

Material e métodos: Doentes internados no Serviço de Pneumologia III do Hospital de Pulido Valente no período compreendido entre Abril de 1999 e Junho de 2007, com o diagnóstico de TBMR microbiologicamente confirmado. Foram analisadas as seguintes variáveis: sexo, distribuição etária, raça, formas de apresentação da TB, grupos de tratamento, perfil de resistência aos antibacilares, estatuto de imigrante, número e duração de tratamentos anteriores, classificação OMS, co-infecção VIH, alcoolismo e/ou toxicodependência, demora média do internamento e mortalidade intra-hospitalar. A análise estatística realizou -se no programa SPSS (Statistical Package for the Social Sciences), versão 15.0.

Nas variáveis categoriais, as diferenças estatísticas entre os grupos foram avaliadas através do teste qui –quadrado e as variáveis numéricas através do teste t. Para a construção do modelo preditivo da presença de TBXDR (variável dependente) foi utilizada a análise de regressão logística, tendo sido incluídas as seguintes variáveis independentes: classificação OMS, coinfecção VIH, estatuto de imigrante, alcoolismo e/ou toxicodependência e número e duração de tratamentos anteriores.

Resultados: Foram contabilizados 132 doentes com TBMR, dos quais 69 (52,3%) eram TBXDR. Observaram -se diferenças estatisticamente significativas nas seguintes variáveis: raça (a raça negra esteve associada a TBXDR em 74% dos casos versus 46% da raça caucasiana); classificação OMS (doentes com retratamento por insucesso terapêutico, interrupção do tratamento ou recidiva constituíram 69,5% dos casos de TBXDR versus 44,5 % dos casos não TBXDR); duração média dos tratamentos anteriores (4,2 meses para os casos de TBXDR versus 2,8 meses para os casos não TBXDR); coinfecção VIH/SIDA (doentes com coinfecção VIH constituíram 65,2% dos casos de TB XDR versus 42,9% dos casos não TBXDR) e mortalidade (33,3% nos doentes com TBXDR versus 14,3% nos doentes não TBXDR).

Conclusões: As variáveis com valor preditivo para o diagnóstico de TBXDR versus não TBXDR foram: presença de infecção VIH (risco relativo [RR] para TBXDR de 2,5; intervalo de confiança [IC], 1,24 - 5,05); maior duração média dos tratamentos anteriores ([RR] para TB XDR de 1,2; [IC], 1,11 -2,30 ).

Palavras-chave: Tuberculose extensivamente resistente (TBXDR), tuberculose multirresistente (TBMR), epidemiologia, valor preditivo.

 

 

Comparative analysis of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis – Epidemiology and predictive factors

Abstract

Introduction: Extensively drug-resistant tuberculosis (XDR-TB) is defined as a form of multidrug-resistant tuberculosis (MDR-TB) with additional resistance to fluoroquinolones and at least one of the injectable drugs used in tuberculosis treatment: amikacin, kanamycin and capreomycin. It was classified by WHO as a serious threat to tuberculosis (TB) control, with world-wide consequences, taking on the proportions of a real pandemic in some regions.

Aim: To compare patients with XDR-TB versus other MDR-TB profiles with regard to epidemiological and demographic characteristics, aetiopathogenic factors and inhospital outcomes.

Methods: Patients admitted to Pulido Valente Hospital (Pulmonology Service III) in the period ranging from April 1999 to June 2007 with MDR-TB diagnosis microbiologically confirmed. The following variables were evaluated: gender, age, race, forms of TB presentation, treatment groups, resistance profile, immigrant status, number and duration of previous treatments, WHO classification, HIV co-infection, alcoholism and/or drug addiction, average length of hospital stay and inhospital mortality. Statistical analysis was performed using the SPSS (Statistical Package for the Social Sciences), version 15.0. In categorical variables, the statistical differences between groups were evaluated by the Chisquare test and numeric variables using the T-test.

Logistical regression analysis was used to build the predictive model of XDR-TB existence (dependent variable), which included the following independent variables: WHO classification, HIV co-infection, immigrant status, alcoholism and/or drug addiction and number and duration of previous treatments.

Results: We recorded 132 patients with MDR-TB, of which 69 (52.3%) were XDR-TB. Statistically significant differences were observed in the following variables: race (black race was associated with XDRTB in 74% of cases versus 46% of the Caucasian race); WHO classification (patients with retreatment for therapeutic failure, stopping treatment or relapse were 69.5% of XDR-TB cases versus 44.5% of Not XDR-TB cases; average duration of previous treatments (4.2 months for XDR-TB cases versus 2.8 months for Not XDR-TB cases); HIV co-infection (patients with HIV co-infection constituted 65.2% of XDR-TB cases versus 42.9% of Not XDR-TB cases), mortality (33.3% in patients with XDR-TB versus 14.3% in Not XDR-TB patients).

Conclusions: The variables with predictive value for the diagnosis of XDR-TB vs. Not XDR-TB were presence of HIV co-infection (odds ratio [OR] for XDRTB 2.5; 95% confidence interval [CI], 1.24 - 5.05) and increased average duration of previous treatments ([OR] for XDR-TB 1.2; 95% [CI], 1.11 – 2.30).

Key-words: Extensively drug-resistant tuberculosis (XDR-TB), multidrug-resistant tuberculosis (MDRTB), epidemiology, predictive value.

 

 

Texto completo disponível apenas em PDF.

Full text only available in PDF format.

 

 

Bibliografia / Bibliography

1. World Health Organization. "WHO Global Task Force outlines measures to combat XDR-TB worldwide". – Geneva, Switzerland, 9-10 October 2006        [ Links ]

2. Migliori GB; Besozzi G, Girardi E, et al. Clinical and operational value of extensively drug-resistant tuberculosis definition. Eur Respir J 2007; 30(4): 623-6.

3. The Global MDR-TB & XDR-TB Response Plan 2007-2008.

4. Neel RG, Mol A, Sturm A, et al. Extensively drugresistant tuberculosis as a cause of death in patients coinfected with tuberculosis and HIV in a rural area of South Africa. Lancet 38 (4): 1575-80.

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6. Maltez F, et al. Extensively drug-resistant tuberculosis – case analysis 2003-2007. 17th International AIDS Conference, Mexico City, abstract MOPDB207, 2008.

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9. Caminero J. Likelihood of generating MDR-TB and XDR-TB under National Tuberculosis Control Programme Implementation. Int J Tuberc Lung Dis 2008; 12(8):869-77.

10. Blaas SH, Mutterlein R, Weig J, Neher A, Salzberger B, Lehn N, Naumann L. Extensively drug resistant tuberculosis in a high income country: a report of four unrelated cases. BMC Infect Dis 2008; 2 (8):60.

11. Banerjee R, Allen J, Westenhouse J, Oh P, Elms W, Desmond E, Nitta A, Royce S, Flood J. Extensively drug-resistant tuberculosis- California, 1993-2006. Clin Infect Dis 2008; 47(4):450.

12. Jeon CY, Hwang SH, et al. Extensively drug-resistant in South Korea: risk factors and treatment outcomes among patients at a tertiary referral hospital. Clin Infect Dis 2008; 46(1):42-9.

13. CDC. extensively drug-resistant tuberculosis – United States, 1993-2006. MMWR 2007; 56:250-3.

 

 

1 Interna do Internato Complementar de Pneumologia / Pulmonology resident anasofia.vilarica@gmail.com

2 Assistente Hospitalar Graduado de Pneumologia / Pulmonology consultant and specialist

3 Chefe de Serviço Hospitalar de Pneumologia e Director do Serviço de Pneumologia III do Hospital de Pulido Valente, Lisboa / Head, Hospital Pulmonology Service and Director, Hospital Pulmonology Service III, Pulido Valente Hospital, Lisbon