浙江地区非结核分枝杆菌在疑似肺结核患者中的流行研究

发布时间：2018-04-07 14:48

本文选题：非结核分枝杆菌　切入点：糖尿病　出处：《浙江大学》2015年博士论文

【摘要】：第一部分浙江地区非结核分枝杆菌在疑似肺结核患者中的流行研究背景非结核分枝杆菌(Nontuberculous mycobacteria, NTM)是抗酸染色阳性的分枝杆菌,在近几年获得了越来越多的关注。因为世界各地区的研究发现,NTM的发病率在普遍上升；而且作为环境中广泛存在的细菌,NTM可以在免疫缺陷患者中引起严重的感染性疾病,累及肺部,皮肤,软组织,骨髓等部位,并常常被误诊为结核病。作者所在课题组,从2011年初开始在浙江省传染病防治示范区收集从疑似肺结核患者的痰标本中培养得到的分枝杆菌菌株,到2013年底已收集了1831位患者的1953株抗酸染色阳性细菌,从中鉴定出113株NTM,来自于100位患者。本研究据此对这些分枝杆菌标本中的NTM菌株和患者进行了研究。目的为了调查疑似肺结核患者中的NTM感染的流行情况,以及患者的一般情况、临床表现、死亡相关因素、社会经济学因素和NTM菌株的耐药情况,在位于我国东南沿海地区的浙江省展开了本研究。方法从2011年1月1日起到2013年12月31日止,通过浙江省示范区的结核病监测网络,收集到来源于100位患者的113株NTM菌株。所有菌株均进行了分枝杆菌菌种鉴定芯片的鉴定和基因测序以获得确认,并进行了相关抗生素的体外液体微量稀释法药敏试验。结果2011年NTM从抗酸染色阳性的分枝杆菌标本中的检出率为5.0%,2012年为6.1%,2013年为6.2%(P0.5)。2011年、2012年及2013年浙江省示范区的NTM肺部感染的发生率分别为3.29/10万(95%CI：1.12-9.69),4.24/10万(95%CI：1.64-10.98),3.33/10万(95%CI：1.14-9.75)。感染者主要包括三类人群：中低收入的中老年男性,流动的从事体力劳动的年轻男性,患有肺气肿等基础肺部疾病的中老年女性。分离和鉴定得到的主要菌种包括胞内分枝杆菌,鸟分枝杆菌,堪萨斯分枝杆菌和脓肿分枝杆菌。经体外药敏试验发现,脓肿分枝杆菌对多种抗生素有很高的耐药比率,所有的堪萨斯分枝杆菌都对利福平敏感,所有的胞内分枝杆菌和乌分枝杆菌都对克拉霉素敏感。结论浙江地区流行的NTM主要包括四种：胞内分枝杆菌,鸟分枝杆菌,堪萨斯分枝杆菌和脓肿分枝杆菌。三类主要的感染人群说明,NTM的肺部感染的发生可能和个体的工作环境、生活环境以及肺部基础疾病具有密切联系。因为浙江地区的脓肿分枝杆菌对常用抗生素具有较高的耐药率,所以在对NTM肺病的患者进行抗分枝杆菌的抗生素治疗以前,需要对致病的NTM进行菌种鉴定,并进行体外药敏试验,采用敏感抗生素的联合治疗方案进行治疗。第二部分浙江地区胞内分枝杆菌的ERIC-PCR基因图谱分析背景ERIC-PCR (Enterbacterial Repetitive Intergenic Consensus-Polymerase Chain Reaction)扩增得到的细菌DNA主要包含基因间的重复保守性序列,可以结合聚类分析方法用来研究同种不同株的细菌间的同源性关系。目的目前没有胞内分枝杆菌可以直接在人与人之间传播和感染的研究证据。因此我们假设在浙江地区流行的胞内分枝杆菌具有高度不同源性,并通过ERIC-PCR对收集的38株胞内分枝杆菌进行了研究和分析。方法从2011年1月1日起到2012年12月31日止,收集到来源于36位患者的37株胞内分枝杆菌和1株胞内分枝杆菌标准株并进行ERIC-PCRo结果每株细菌都有扩增产物,产物大小介于100bp-2000bp,条带数目介于3-12条。38株胞内分枝杆菌的ERIC-PCR指纹图谱具有程度不一的差异,没有条带完全相同的指纹图谱结论ERIC-PCR是可以被用来对胞内分枝杆菌进行分子分型和同源性检测的实验技术。浙江地区流行的胞内分枝杆菌的同源性程度很低。第三部分多重耐药非结核分枝杆菌致多发性骨髓炎病例的研究报道非结核分枝杆菌(Nontuberculous mycobacteria, NTM)是近年来获得重视和关注的一类重要的机会性致病菌,不仅可以感染肺部,还可以累及骨髓、皮肤、淋巴结等全身多处器官,在免疫缺陷患者中造成后果严重的感染。但是因为发病率低,所以长期未获得重视和了解。糖尿病患者也属于免疫缺陷的人群,因此由各种病原菌引起的骨髓炎也是糖尿病患者中一类重要的并发症,但是世界范围内的已发表文献中只有很少的病例报道是关于糖尿病患者中发生的NTM骨髓炎。在这个病例报道中,我们报告了一例69岁的来自浙江地区的男性糖尿病患者,先被诊断为结核性骨髓炎。后来借助基因芯片技术被确诊为胞内分枝杆菌感染引起的全身多发性的骨髓炎,并通过体外药敏试验和23S-rDNA直接测序技术确认发生了对大环内酯类抗生素耐药的突变。尽管如此,多种抗生素的联合治疗方案在这个病人身上仍然取得了控制感染的效果。在讨论部分我们进行了文献检索,根据目前世界范围内的英语文献情况对糖尿病患者中的NTM骨髓炎的发生情况进行了综述。
[Abstract]:Non Mycobacterium tuberculosis in a suspected epidemic background of pulmonary tuberculosis patients in non Mycobacterium tuberculosis in Zhejiang area the first part (Nontuberculous mycobacteria NTM) is a positive acid fast stain Mycobacterium, get more and more attention in recent years. Because the study area around the world found that the incidence of NTM in general increase; and as the environment is widely existed in bacteria, NTM can cause serious infectious disease in immunodeficient patients involving the lungs, skin, soft tissue, bone marrow, and is often misdiagnosed as tuberculosis. The author's research group, began collecting the infectious disease prevention and treatment demonstration area in Zhejiang province from sputum samples of suspected pulmonary tuberculosis patients in the culture of Mycobacterium strains obtained from early 2011 to the end of 2013, has collected 1831 patients with 1953 strains of acid fast stain positive bacteria, 113 strains of NTM from identified from 100 Patients in this study. The study of these specimens in Mycobacterium strains and NTM patients. Objective to study the prevalence of suspected pulmonary tuberculosis in NTM infected patients, and in general, patients with clinical manifestations, death related factors, social economic factors and drug resistance of strain NTM, located in the southeast coastal area China's Zhejiang Province carried out this study. Methods from January 1, 2011 to December 31, 2013, the TB monitoring network demonstration zone in Zhejiang Province, collected from 113 NTM strains from 100 patients. All strains were identified and sequenced Mycobacterium species identification chip to be confirmed, and in vitro microdilution susceptibility test of antibiotics were carried out. The results of 2011 NTM from Mycobacterium detection acid fast stain positive specimens in the rate of 5%, 6.1% in 2012, 2013 Year 6.2% (P0.5).2011, 2012 and 2013 in Zhejiang Province demonstration area NTM lung infection incidence rate was 3.29/10 million (95%CI:1.12-9.69), 4.24/10 million, 3.33/10 million (95%CI:1.64-10.98) (95%CI:1.14-9.75). The infection mainly includes three groups: low-income older men, the flow of manual labor a young man suffering from emphysema of lung disease in elderly women. The main strain was separated and identified including Mycobacterium intracellulare and Mycobacterium avium, Kansas Mycobacterium tuberculosis and Mycobacterium abscessus. The drug sensitivity test in vitro showed that Mycobacterium abscessus has a high rate of resistance to multiple antibiotics, all Kansas Mycobacterium are sensitive to rifampin, all Mycobacterium intracellulare and Mycobacterium Ukraine are sensitive to clarithromycin. Conclusion epidemic in Zhejiang area NTM mainly includes four kinds: intracellular Mycobacterium Coli, Mycobacterium avium and Mycobacterium abscessus and Kansas. Three main types of infections that may occur and the individual working environment of NTM pulmonary infection, living environment and lung diseases are closely linked. Because the resistance of Mycobacterium abscessus in Zhejiang area has a high rate of antibiotics, antibiotic treatment and so anti Mycobacterium pulmonary disease in NTM patients before, the need for pathogenic NTM strain identification, and drug sensitivity test in vitro, using combination therapy of sensitive antibiotic treatment. ERIC-PCR gene of Mycobacterium intracellular region analysis of the second part of the Zhejiang ERIC-PCR (Enterbacterial Repetitive Intergenic Consensus-Polymerase background Chain Reaction) amplification of bacteria DNA mainly includes repeat conserved sequences between genes, can be combined with clustering analysis The method used to study the different strains of bacteria homology relationship. There is no purpose of m.intracellulare can be directly transmitted from person to person and the infection of evidence. So we hypothesized that popular in the Zhejiang area of m.intracellulare highly different sources, and through the ERIC-PCR 38 cell lines to collect in mycobacteria were studied and analyzed. Methods from January 1, 2011 to December 31, 2012, were collected from 36 patients with 37 m.intracellulare and 1 m.intracellulare standard strain and ERIC-PCRo results of each strain has amplified products, product size is 100bp-2000bp, ERIC-PCR fingerprint bands ranged from 3-12.38 m.intracellulare have different degrees of bands, not exactly the same conclusion ERIC-PCR fingerprint that can be used for the m.intracellulare Molecular typing and homology detection experiment technology. Zhejiang area popular m.intracellulare homology degree is very low. The third part multi drug resistant studies reported multiple osteomyelitis cases caused by Mycobacterium tuberculosis non Mycobacterium tuberculosis (Nontuberculous mycobacteria NTM) is a kind of important opportunistic get attention and concern in recent years the pathogens of pulmonary infection, not only can, but also can affect the skin, bone marrow, lymph node and multiple body organs, causing serious consequences of infection in immunocompromised patients. But because of the low incidence, so long did not get attention and understanding. Diabetic patients also belong to immunocompromised people, therefore caused by various pathogenic bacteria osteomyelitis is an important type of diabetes complications, but the world has published only a few cases reported in the literature on diabetes patients In the NTM in the osteomyelitis. Case report, we report the case of a 69 year old from the Zhejiang area men with diabetes, first diagnosed as tuberculous osteomyelitis. Then by means of gene chip technology was diagnosed with Mycobacterium intracellulare infection caused by systemic multiple osteomyelitis, and the drug sensitivity in vitro test and 23S-rDNA sequencing confirmed that mutations of macrolide resistance. However, combination therapy of antibiotics still achieved control effect of infection in this patient. In the discussion section we conducted a literature search, according to the current situation of English literature in the world of diabetic patients. NTM osteomyelitis was reviewed.

【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R181.3

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