基于meta分析的诱导痰和自咳痰样品结核杆菌阳性检出率的比较

摘要/Abstract

摘要： 目的通过meta分析使用诱导痰技术相较于自咳痰对肺结核患者痰涂片、分子生物学技术和痰培养检测方法的结核杆菌阳性检出率是否具有优势。方法在中国知网、万方数据库、维普数据库、Pubmed、Cochrane图书馆和Embase数据库中检索自建库至2024年1月前发表的相关文献,并由2位研究人员根据所制定的纳入与排除标准筛选合适的研究。采用R 4.3和Stata 14.0软件进行meta分析,使用固定效应模型估计总体比值比（OR）及其95%置信区间（95%CI）。使用纽卡斯尔-渥太华量表（newcastle-ottawa scale,NOS）对纳入的文献进行质量评价,meta分析结果以森林图、帷幔图、敏感性分析、亚组分析展示,通过Egger直线回归结果、Begg秩相关检验结果和剪补漏斗图矫正发表偏倚。结果共检索到528篇文献,最后纳入11篇文献,这些研究都在结核病高负担国家中进行。痰诱导获得合格样本量3 575例,自咳痰获得合格样本量3 407例,诱导痰的成功率为78.90%~100.00%。Meta分析结果显示,诱导痰技术检测肺结核患者的结核分枝杆菌的阳性检出率是自咳痰技术的1.87倍（95%CI：1.66~2.09,P<0.01）,各研究间不存在异质性（I²=0,P>0.05）。根据临床诊断分类、样本检测方法、痰液的前处理、生理盐水浓度和诱导时长等差异进行亚组分析,结果与总体一致。Egger直线回归法（t=2.767,P<0.05）和Begg秩相关检验（Z=2.352,P<0.05）显示存在发表偏倚,通过剪补法校正发表偏倚认为原始结果是可信的。结论与自咳痰取痰相比,诱导痰技术可以提高肺结核患者痰样本的阳性检出率,是一种安全、便捷和经济的操作方法。

关键词: 诱导痰, 结核分枝杆菌, 肺结核, Meta分析, 帷幔图

Abstract: Objective To explore whether the use of induced sputum technique has an advantage over self-expectoration on the positive detection rate of Mycobacterium tuberculosis through sputum smears,molecular biology techniques and sputum culture methods in tuberculosis（TB） patients through meta-analysis. Methods Retrieve relevant literature published since the establishment of the database until January 2024 from China National Knowledge Infrastructure（CNKI） Database,Wanfang Database,China Science and Technology Journal Database,Pubmed,Cochrane Library,and Embase Database. Two researchers selected appropriate studies according to the established inclusion and exclusion criteria. Meta-analysis was performed with R 4.3 and Stata 14.0 software, and fixed-effects model was used to estimate the overall odds ratio（OR） and its 95%CI. The Newcastle-Ottawa Scale（NOS） was used to assess the quality of the included literature,and meta-analysis results were presented in forest plots,drapery plot,sensitivity analysis,and subgroup analysis. Publication bias was corrected by Egger's linear regression,Begg's rank correlation test,and contour-enhanced funnel plots. Results A total of 528 articles were retrieved,among which 11 literatures met the inclusion criteria. All of the studies were conducted in high TB burden countries. The number of eligible samples obtained was 3 575 for sputum induction and 3 407 for self-expectoration,and the success rate of sputum induction ranged from 78.90% to 100.00%. Meta-analysis results showed that the positive detection rate of Mycobacterium tuberculosis in pulmonary tuberculosis patients detected by sputum induction technique was 1.87 times higher than that of self-expectoration technique（95%CI：1.66-2.09,P<0.01）,and there was no heterogeneity among included studies（I²=0,P>0.05）. Subgroup analysis by clinical diagnostic classification,sample testing method,pretreatment of sputum,saline concentration,and induction duration showed consistent results with the overall results. Egger's linear regression（t=2.767,P<0.05） and Begg's rank correlation test（Z=2.352,P<0.05） showed publication bias,and the original results were considered reliable after correcting for publication bias through trim and fill method. Conclusion Compared with self-expectoration,the induced sputum technique can improve the positive detection rate of sputum samples from TB patients,and is a safe,convenient and cost-effective method of operation.

Key words: Sputum induction, Mycobacterium tuberculosis, Pulmonary tuberculosis, Meta-analysis, Drapery plot

张潇旖, 汉锋, 张哲. 基于meta分析的诱导痰和自咳痰样品结核杆菌阳性检出率的比较. [J]职业与健康, 2025, 41(11): 1545-1551.

ZHANG Xiaoyi, HAN Feng, ZHANG Zhe. Comparison between sputum induction and self-expectoration samples in the positive detection rates of Mycobacterium tuberculosis based on mete-analyses. [J]OCCUPATION AND HEALTH, 2025, 41(11): 1545-1551.

参考文献

[1] MARGARIT A,SIMÓS,ROZAS L,et al.Adolescent tuberculosis;a challenge and opportunity to prevent community transmission[J].An Pediatr(Barc),2017,86(3):110-114.
[2] BAGCCHI S.WHO's Global Tuberculosis Report 2022[J].Lancet Microbe,2023,4(1):e20.
[3] World Health Organization.Global tuberculosis report 2023[R].Geneva:World Health Organization,2023.
[4] VLACHOS-MAYER H,LEIGH R,SHARON R F,et al.Success and safety of sputum induction in the clinical setting[J].Eur Respir J,2000
16(5):997-1000.
[5] POPOV T A,PIZZICHINI M M,PIZZICHINI E,et al.Some technical factors influencing the induction of sputum for cell analysis[J].Eur Respir J,1995,8(4):559-565.
[6] LI L M,BAI L Q,YANG H L,et al.Sputum induction to improve the diagnostic yield in patients with suspected pulmonary tuberculosis[J].Int J Tuberc Lung Dis,1999,3(12):1137-1139.
[7] PIN I,GIBSON P G,KOLENDOWICZ R,et al.Use of induced sputum cell counts to investigate airway inflammation in Asthma[J].Thorax,1992, 47(1):25-29.
[8] PAGGIARO P L,CHANEZ P,HOLZ O,et al.Sputum induction[J].Eur Respir J,2002,37:3s-8s.
[9] HENSLER N M,SPIVEY CG J R,DEES T M.The use of hypertonic aerosol in production of sputum for diagnosis of tuberculosis.Comparison with gastric specimens[J].Dis Chest,1961,40:639-642.
[10] KELLERMAN S,JARVIS T W R.The cost of selected tuberculosis control measures at hospitals with a history of Mycobacterium tuberculosis outbreaks[J].Infect Contr Hosp Epi,1997,18(8):542-547.
[11] MOHIUDDIN L G M.Switching from expectorated to induced sputum cultures for tuberculosis diagnosis reduces cost without increasing risk[J].Am J Infect Contr,2019,47(8):1-3.
[12] ANDERSON C,INHABER N,et al.MENZIES D.Comparison of Sputum Induction with Fiberoptic Bronchoscopy in the Diagnosis of Tuberculosis[J].Am J Respirat Critical Care Med,2000,162(6):2238-2240.
[13] 周晔. 高渗盐水雾化吸入诱导肺结核患者取痰标本的应用及护理[J].中国实用医药,2015,10(7):232-233.
[14] BUTOV D,FESHCHENKO Y,MYASOEDOV V,et al.Effectiveness of inhaled hypertonic saline application for sputum induction to improve Mycobacterium tuberculosis identification in patients with pulmonary tuberculosis[J].Wien Med Wochenschr,2022,172(11-12):261-267.
[15] 盛明亮,徐新养.高渗盐水雾化吸入诱导痰中抗酸杆菌的检测意义[J].蚌埠医学院学报,2006(4):399-400.
[16] 李站领,李艳静,彭勋等.常规痰与梯度高渗盐水超声雾化法诱导痰抗酸染色阳性率对比研究[J].河北医药,2012,34(9):1302-1303.
[17] 刘晓灵,段明玲,袁小兰,等.高渗盐水雾化诱导取痰在无痰肺结核患者中的应用价值[J].四川医学,2014,35(12):1585-1587.
[18] JIANG Q,JI L,QIU Y,et al.A randomised controlled trial of stepwise sputum collection to increase yields of confirmed tuberculosis[J]. Int J Tubercu Lung D,2019,23(6):685-691.
[19] 王利华,张晓磊,金龙.不同取痰方法在结核杆菌检测方法中的比较分析[J].齐齐哈尔医学院学报,2020,41(13):1704-1705.
[20] ATIQ-UR-REHMAN M,NASEEM A,HUSSAIN T.Comparison of diagnostic yield of AFB with sputum induction to spontaneous sputum examination in suspected pulmonary tuberculosis[J].J Coll Physicians Surg Pak,2009,19(8):506-509.
[21] 李秋根,刘江红,边泽源.不同检测方法对肺结核诊断价值的探讨[J].中国危重病急救医学,2002,14(9):543-544.
[22] BAGHERI K H,AFRASIABIAN S,MOHSENPOUR B,et al.Spontaneous and induced sputum values in the diagnosis of pulmonary tuberculosis among patients with suspected pulmonary tuberculosis[J].Ann Trop Med Public Health,2015,8:253-257.
[23] 严明. 诱导排痰在儿童肺结核诊断中的应用价值[J].湖北中医杂志,2010,32(2):35.
[24] The Canadian Lung Association and the Public Health Agency of Canada.CANADIAN TUBERCULOSIS STANDARDS 7th ed[EB/OL].(2014-02-17)[2024-10-11].https://www.canada.ca/en/public-health/services/infectious-diseases/canadian-tuberculosis-standards-7th-edition.html.
[25] STANG A.Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses[J].Eur J Epidemiol,2010,25(9):603-605.
[26] LO C K,MERTZ D,LOEB M.Newcastle-Ottawa Scale:comparing reviewers' to authors' assessments[J].BMC Med Res Methodol,2014:14-45.
[27] HIGGINS J P,THOMPSON S G,DEEKS J J,et al.Measuring inconsistency in meta-analyses[J].BMJ,2003,327(7414):557-560.
[28] RÜCKER G,SCHWARZER G.Beyond the forest plot:The drapery plot[J].Res Synth Methods,2021,12(1):13-19.
[29] BEGG C B,MAZUMDAR M.Operating characteristics of a rank correlation test for publication bias[J].Biometrics,1994,50(4):1088-1099.
[30] MATTHIAS EGGER,GEORGE DAVEY SMITH,DOUGLAS ALTMAN.Systematic reviews in health care:meta-analysis in context, 2nd ed[M].London:BMJ Books,2001:363-364.
[31] TAYLOR S J,TWEEDIE R I.Practical estimates of the effect of publication bias in meta-analysis[J].Australas Epidemiol,1998,5:14-17.
[32] 路丽苹,朱云,戴婉琴等.雾化吸入导痰技术对肺结核病原学阳性检出率的影响[C]//中国防痨协会,重庆智飞生物制品股份有限公司.中国防痨协会第32届全国学术大会暨首届中国防痨科技奖颁奖大会论文汇编,浙江:宁波,2018:4.
[33] 张天嵩,熊茜,袁婷.附加轮廓线漏斗图的绘制在R软件中的实现[J].循证医学,2013,13(5):307-309,313.
[34] PETERS J L,SUTTON A J,JONES D R,et al.Contour-enhanced meta-analysis funnel plots help distinguish publication bias from other causes of asymmetry[J].J Clin Epidemiol,2008,61(10):991-996.
[35] GOLUB J E,BUR S,CRONIN W A,et al.Delayed tuberculosis diagnosis and tuberculosis transmission[J].Int J Tuberc Lung Dis,2006, 10(1):24-30.
[36] CONDE M B,SOARES S L MELLO F C.et al.Comparison of sputum induction with fiberoptic bronchoscopy in the diagnosis of tuberculosis:Experience at an acquired immune deficiency syndrome reference center in Rio de Janeiro,Brazil[J].Am Respir Crit Care Med,2000, 162(6):2238-2240.
[37] HEPPLE P,FORD N,MCNERNEY R.Microscopy compared to culture for the diagnosis of tuberculosis in induced sputum samples:A systematic review[J].Int J Tuberc Lung Dis,2012,16(5):579-588.
[38] SHAMIM M A,MANNA S,DWIVEDI P,et al.Minocycline in depression not responding to first-line therapy:A systematic review and meta-analysis[J].Medicine(Baltimore),2023,102(45):e35937.
[39] GOLESTANI A,SHOBEIRI P,SADEGHI-NAINI M,et al.Epidemiology of ttraumatic spinal cord Injury in developing countries from 2009 to 2020:A systematic review and meta-analysis[J].Neuroepidemiology,2022,56(4):219-239.