【摘要】 目的分析上海市结核病耐药状况及其影响因素,为进一步制定结核病防控措施提供依据。方法 2013—2017年上海市新登记肺结核患者34 165例,其中9746株培阳分枝杆菌菌株由当地结核病定点医院送至上海市疾病预防控制中心进行菌群鉴定和固体比例法药物敏感性试验（简称"药敏试验"）。排除1377株（14.13%）非结核分枝杆菌、307株（3.15%）无药敏试验结果、63株（0.65%） 15岁以下患者的菌株、556株（5.70%）登记号缺失或重复的菌株,最终纳入7443株（76.37%）结核分枝杆菌菌株进行分析。利用SAS 9.4软件分析上海市结核病耐药特征,计数资料采用χ²检验,当理论频数<5时采用Fisher确切概率法计算双侧P值;采用Cochran-Mantel-Haenszel检验进行趋势性分析;采用非条件logistic回归模型分析耐药结核病与耐多药结核病的影响因素,检验水准α=0.05。结果 2013—2017年上海市结核病总耐药率、耐多药率和多耐药率分别为21.03%（1565/7443）、4.98%（371/7443）和4.16%（310/7443）,其中前两者呈现下降趋势(χ_趋势²=15.685,P=0.004;χ_趋势²=6.554,P=0.011)。上海市2013—2017年结核病患者对任意耐利福平、异烟肼、链霉素和乙胺丁醇的总耐药率分别为6.01%（447/7443）,11.41%（849/7443）,15.75%（1172/7443）和4.61%（343/7443）,4种药物的总耐药率均有下降的趋势,差异均有统计学意义(χ_趋势²=7.777,P=0.005;χ_趋势²=7.221,P=0.007;χ_趋势²=9.260,P=0.002;χ_趋势²=20.562,P=0.000)。结核病患者对单耐药、耐2种、耐3种、耐4种药的总耐药率分别为11.88%（884/7443）、4.25%（316/7443）、2.22%（165/7443）、2.69%（200/7443）。多因素logistic回归分析显示,≥65岁患者发生耐药与耐多药结核病的风险较低（β=-0.543,Waldχ²=23.036,P<0.001,OR=0.581,95%CI:0.466～0.725;β=-0.797,Waldχ²=11.538,P=0.001,OR=0.451,95%CI:0.285～0.714）,复治患者发生耐药和耐多药结核病的风险较高（β=0.904,Waldχ²=93.722,P<0.001,OR=2.469,95%CI:2.056～2.964;β=1.636,Waldχ²=153.545,P<0.001,OR=5.135,95%CI:3.964～6.652）。结论上海市结核病的耐药情况处于较低水平,呈逐年下降趋势。耐药与耐多药结核病的发生风险在≥65岁患者中较低,在复治患者中较高。更多还原

【Abstract】 Objective To analyze the status and risk factors of drug-resistant tuberculosis in Shanghai,and provide the basis for further developing the prevention and control measures.Methods A total of 34 165 patients with pulmonary tuberculosis were newly registered in Shanghai from 2013 to 2017,of which 9746 sputum culturepositive mycobacteria strains were sent to the Shanghai Center for Disease Control and Prevention by local designated tuberculosis hospitals,and received bacterial identification and solid proportional drug susceptibility testing.The following strains were excluded,including 1377 strains（14.13%） of non-tuberculous mycobacteria,307 strains（3.15%） without drug susceptibility testing results,63 strains（0.65%） of patients under 15 years old,556 strains（5.70%） strains with missing or duplicated accession numbers.Finally,7443（76.37%） Mycobacterium tuberculosis（MTB） strains were included for analysis.SAS 9.4 software was used to analyze the characteristics of drug-resistant tuberculosis in Shanghai.The count data were analyzed by χ² test,while when the theoretical frequency was <5,Fisher’ s exact probability method was used to calculate the bilateral P value;trend analysis was performed by Cochran-Mantel-Haenszel test;the influencing factors of drug-resistant tuberculosis and multidrugresistant tuberculosis were analyzed by unconditional logistic regression model,and the test level was α=0.05.Results The total drug resistance rate,multidrug resistance rate and multiple drug resistance rate of tuberculosis in Shanghai from 2013 to 2017 were 21.03%（1565/7443）,4.98%（371/7443） and 4.16%（310/7443）,respectively,of which the first two showed a downward trend(χ_trend²=15.685,P=0.004;and χ_trend²=6.554,P=0.011).The total drug resistance rates of tuberculosis patients resistant to any rifampicin,isoniazid,streptomycin and ethambutol in Shanghai from 2013 to 2017 were 6.01%（447/7443）,11.41%（849/7443）,15.75%（1172/7443）,and 4.61%（343/7443）,respectively.The total drug resistance rates of all four drugs showed downward trend,with the statistically significant difference(χ_trend²=7.777,P=0.005;χ_trend²=7.221,P=0.007;χ_trend²=9.260,P=0.002;χ_trend²=20.562,P=0.000).The total drug resistance rates of tuberculosis patients resistant to single drug,two drugs,three drugs,and four drugs were 11.88%（884/7443）,4.25%（316/7443）,2.22%（165/7443）,and2.69%（200/7443）,respectively.Multivariate logistic regression analysis showed that the prevalence of drug-resistant and multidrug-resistant tuberculosis was lower in patients aged≥65 year（β=-0.543,Wald χ²=23.036,P<0.001,OR=0.581,95% CI:0.466-0.725;β=-0.797,Wald χ2=11.538,P=0.001,OR=0.451,95%CI:0.285-0.714）,and re-treatment was a risk factor for drug-resistant and multidrug-resistant tuberculosis（β=0.904,Wald χ²=93.722,P<0.001,OR=2.469,95% CI:2.056-2.964;β=1.636,Wald χ²=153.545,P<0.001,OR=5.135,95% CI:3.964-6.652）.Conclusion The drug resistance status of tuberculosis is at a low level in Shanghai,showing a downward trend year by year.The prevalence of drug-resistant and multidrug-resistant tuberculosis is lower in patients aged≥65 years,and higher in patients with re-treatment.更多还原