背景:非结核分枝杆菌是越来越多地引起慢性和衰弱性肺部感染的环境生物,其中鸟分枝杆菌复合体(MAC)是最常见的病原体。MAC肺病(MAC-PD)通常难以治疗,通常需要长期的多药抗生素治疗。
目的:各种基于指南的三药治疗(GBT)方案与治疗相关的不良事件或方案改变/停药之间是否存在关联?
方法:在一项回顾性队列研究中,我们在4,626名美国医疗保险患者支气管扩张患者中检查了GBT方案对MAC-PD的耐受性结果,在2006年至2014年期间,他们被处方GBT作为推定的MAC-PD的初始抗生素治疗。使用多变量Cox比例风险回归,我们估计了校正风险比(aHRs),以比较各种GBT方案在开始治疗后12个月内发生不良事件的风险和方案改变/停药的风险.
结果:该队列在治疗开始时的平均年龄±SD为77.9±6.1岁,大部分是女性(77.7%),大部分是非西班牙裔白人(87.2%)。基于克拉霉素的方案在治疗12个月内改变/停药的风险高于基于阿奇霉素的方案(aHR,1.12;95%CI,利福平1.04-1.20;AHR,1.11;95%CI,0.93-1.32,以利福布丁为伴侣利福霉素),对于含有利福布汀的方案,而不是含有利福平的方案(AHR,1.49;95%CI,阿奇霉素为1.33-1.68;aHR,1.47;95%CI,1.27-1.70,克拉霉素作为伴侣大环内酯)。与克拉霉素-乙胺丁醇-利福布汀和阿奇霉素-乙胺丁醇-利福平的方案改变/停药比较的aHR为1.64(95%CI,1.43-1.64)。
结论:总体而言,基于阿奇霉素的方案比基于克拉霉素的方案更不可能改变或停用,在治疗开始后12个月内,与含利福布汀的方案相比,含利福平的方案改变或停用的可能性较小.我们的工作提供了对用于治疗MAC-PD的多药抗生素方案的耐受性的基于人群的评估。
BACKGROUND: Nontuberculous mycobacteria are environmental organisms that are increasingly causing chronic and debilitating pulmonary infections, of which Mycobacterium avium complex (MAC) is the most common pathogen. MAC pulmonary disease (MAC-PD) is often difficult to treat, often requiring long-term multidrug antibiotic therapy.
OBJECTIVE: Is there an association between various
guideline-based three-drug therapy (GBT) regimens and (1) therapy-associated adverse events or (2) regimen change/discontinuation, within 12 months of therapy initiation?
METHODS: In a retrospective cohort study, we examined tolerability outcomes of GBT regimens for MAC-PD in 4,626 US Medicare beneficiaries with bronchiectasis, who were prescribed a GBT as initial antibiotic treatment for presumed MAC-PD during 2006 to 2014. Using multivariable Cox proportional hazard regression, we estimated adjusted hazard ratios (aHRs) to compare the risk of adverse events and regimen change/discontinuations within 12 months of therapy initiation in various GBT regimens.
RESULTS: The cohort had a mean age ± SD of 77.9 ± 6.1 years at treatment start, were mostly female (77.7%), and were mostly non-Hispanic White (87.2%). The risk of regimen change/discontinuation within 12 months of therapy was higher for clarithromycin-based regimens than azithromycin-based regimens (aHR, 1.12; 95% CI, 1.04-1.20 with
rifampin; aHR, 1.11; 95% CI, 0.93-1.32 with rifabutin as the companion rifamycin), and for rifabutin-containing regimens than
rifampin-containing regimens (aHR, 1.49; 95% CI, 1.33-1.68 with azithromycin; aHR, 1.47; 95% CI, 1.27-1.70 with clarithromycin as the companion macrolide). The aHR comparing regimen change/discontinuation with clarithromycin-ethambutol-rifabutin and azithromycin-ethambutol-
rifampin was 1.64 (95% CI, 1.43-1.64).
CONCLUSIONS: Overall, an azithromycin-based regimen was less likely to be changed or discontinued than a clarithromycin-based regimen, and a
rifampin-containing regimen was less likely to be changed or discontinued than a rifabutin-containing regimen within 12 months of therapy start. Our work provides a population-based assessment on the tolerability of multidrug antibiotic regimens used for the treatment of MAC-PD.