POLİKLİNİK HASTALARININ İDRAR KÜLTÜRLERİNDEN İZOLE EDİLEN ESCHERICHIA COLI VE KLEBSIELLA PNEUMONIAE SUŞLARININ GENİŞLEMİŞ SPEKTRUMLU BETA-LAKTAMAZ ÜRETİM ORANLARI VE ANTİBİYOTİK DUYARLILIKLARININ DEĞERLENDİRİLMESİ
Abstract
Üriner sistem infeksiyonları (ÜSİ), infeksiyon hastalıkları pratiğinde en sık karşılaşılan hastalıklardan biridir. Komplike olmayan ÜSİ’lerin % 75-95’inden Gram negatif bakteriler sorumludur. Hem komplike hem de komplike olmayan ÜSİ’lerde en sık izole edilen etken Escherichia coli’dir. Gram negatif bakteriler arasında, E.coli’den sonra en sık izole edilen patojen Klebsiella pneumoniae’dır. ÜSİ’de en sık etkenler olarak karşımıza çıkan E.coli ve K.pneumoniae’da, genişlemiş spektrumlu beta-laktamaz (GSBL) enzimi varlığı her geçen gün artmaktadır.
Toplum kökenli infeksiyonlarda da artan bu direnç profili, özellikle birinci basamak tedavide, ampirik antibiyotik tedavisi seçiminde önemli bir sorundur. Çalışmamızda, üriner sistem yakınmaları ile polikliniğe başvuran hastaların idrar kültürlerinden izole edilen, E.coli ve K.pneumoniae’da GSBL oranlarını ve antibiyotik direnç profillerini inceleyerek, ampirik antibiyotik tedavi seçimine yardımcı olmayı amaçladık.
Bu çalışma, Yozgat Şehir Hastanesi’nde üriner sistem şikayeti olan poliklinik hastalarından mikrobiyoloji laboratuvarına gönderilen idrar kültürlerinin retrospektif olarak incelenmesi ile yapılmıştır. Ocak 2017 ve Şubat 2018 tarihleri arasında idrar kültüründe üreyen 524 E.coli ve 104 K.pneumoniae çalışmaya dahil edilmiştir. Her bir hasta için sadece bir izolat çalışmaya alınmıştır. Bakteri tanımlaması ve antibiyotik duyarlılık testleri konvansiyonel yöntemler ve otomatize sistemler kullanılarak yapılmıştır.
İzole edilen E.coli ve K.pneumoniae suşlarının GSBL pozitiflik oranları sırası ile % 29.9 ve % 28.8 olarak saptanmıştır ve bu iki bakteri karşılaştırıldığında GSBL üretimi açısından istatistiki olarak anlamlı fark bulunmamıştır (p=0.9). E.coli suşlarının en duyarlı olduğu antibiyotik meropenem (% 99) iken, etkinlik oranı en düşük antibiyotik ise ampisilin (% 42.6) olarak saptanmıştır. K.pneumoniae suşlarında doğal direnç olduğu için ampisilin değerlendirme dışı bırakılmıştır. K.pneumoniae’nın en duyarlı olduğu antibiyotik imipenem (% 98.9) iken,
etkinlik oranı en düşük antibiyotik ise nitrofurantoin (% 56.9) olarak bulunmuştur. GSBL pozitif izolatlar değerlendirildiğinde etkinliği en düşük antibiyotiğin E.coli’de ampisilin, K.pneumoniae’da ise sefuroksim olduğu görülmüştür.
Sonuç olarak, ülkemizde ve dünyada yapılmış pek çok çalışmaya benzer şekilde GSBL üreten suş oranlarının yüksek olduğu ve busuşlarda beklendiği üzere antibiyotik duyarlılık oranlarının daha düşük olduğu görülmektedir. Günlük pratiğimizde sık kullanılan trimetoprim ve sefalosporinlere karşı yüksek direnç oranları olduğu unutulmamalıdır. Her bölgenin kendi antibiyotik direnç profilini ortaya koyması ayrıca önemlidir. Mevcut antibiyotik direnç verilerinin in vitro şartlarda yapıldığı ve klinik kullanımda etkinliğini gösteren geniş çaplı araştırmalara ihtiyaç olduğunu düşünmekteyiz.
Keywords
Escherichia coli genişlemiş spektrumlu beta-laktamaz Klebsiella pneumoniae üriner sistem infeksiyonu
References
- Ağca H. Escherichia coli ve Klebsiella pneumoniae suşlarının genişlemiş spektrumlu beta-laktamaz üretimleri ve antibiyotik duyarlılık oranları, DEÜ Tıp Fak Derg. 2011;25(3):169-73.
- Canton R, Novais A, Valverde A, et al. Prevalence and spread of extended-spectrum beta-lactamaseproducing Enterobacteriaceae in Europe, Clin Microbiolol Infect. 2008;14(Suppl 1):144-53.
- Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: Twenty-first Informational Supplement M 100-S21. CLSI, Wayne, PA, USA, (2011).
- Del Carmen Rodriguez M, Vera DE, RamirezRonda CH, Saavedra S. Phenotypic confirmation of extended-spectrum B-lactamases (ESBL) in clinical isolates of Escherichia coli and Klebsiella pneumoniae at the San Juan Veterans Affairs Medical Center, P R Health Sci J. 2004;23(3):207-15. PMID: 15631176.
- Ece GT, Tunçel BM. Bir üniversite hastanesine gönderilen idrar kültürlerinde üreyen izolatların dağılımı ve antimikrobiyal duyarlılık profilinin incelenmesi, Ege Tıp Derg. 2013;52(3):136-40.
- European Committee on Antimicrobial Susceptibility Testing Breakpoint tables for interpretation of MICs and zone diameters Version 7.1, Erişim Adresi: http://www.eucast.org/fileadm i n / s r c / m e d i a / P D F s / E U C A S T _ f i l e s /Breakpoint_tables/v_7.1_Breakpoint_Tables.pdf. Erişim Tarihi: 22.04.2018
- Falagas ME, Vouloumanou EK, Togias AG, et al. Fosfomycin versus other antibiotics for the treatment of cystitis: a meta-analysis of randomized controlled trials, J Antimicrob Chemother 2010;65(9):1862-77. https://doi.org/10.1093/jac/dkq237PMID: 20587612.
- Ferraro G, Ambrosi G, Bucci L, Palmieri R, Palmieri G. Fosfomycin trometamol versus norfloxacin in the treatment of uncomplicated lower urinary tract infections of the elderly, Chemotherapy 1990;36(Suppl 1):46-9. https://doi.org/10.1159/000238817PMID: 2085990.
- Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs, Dis Mon. 2003;49(2):53-70. PMID: 12601337. https://doi.org/10.1016/S0002-9343(02)01054-9
- Galindo-Mendez M. Molecular characterization and antimicrobial susceptibility pattern of extended-spectrum beta-lactamase-producing Escherichia coli as cause of community acquired urinary tract infection, Rev Chilena Infectol. 2018;35(1):29-35. https://doi.org/10.4067/s0716-10182018000100029
- Garau J. Other antimicrobials of interest in the era of extended-spectrum beta-lactamases: fosfomycin, nitrofurantoin and tigecycline, Clin Microbiol Infect. 2008;14(Suppl 1):198-202. https://doi.org/10.1111/j.1469-0691.2007.01852.x
- Gündem NS, Çıkman A, Gülhan B. İdrar kültürlerinden izole edilen Escherichia coli ve Klebsiella spp. suşlarının genişlemiş spektrumlu betalaktamaz (GSBL) üretimi ve antibiyotik direnci, JCEI 2013;4(1):56-62. https://doi.org/10.5799/ahinjs.01.2013.01.0234
- Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases, Clin Infect Dis 2011;52(5):e103-20. https://doi.org/10.1093/cid/ciq257.PMID: 21292654.
- Hooton TM, Pacita L, Roberts MS, et al. Voided Midstream Urine Culture and Acute Cystitis in Premenopausal Women, N Engl J Med. 2013;369(20):1883-91. PMID: 24224622 https://doi.org/10.1056/NEJMoa1302186
- Hooton TM. Clinical practice. Uncomplicated urinary tract infection, N Engl J Med. 2012; 366(11):1028-37. PMID: 22417256. https://doi.org/10.1056/NEJMcp1104429
- Kader AA, Angamuthu K. Extended-spectrum beta-lactamases in urinary isolates of Escherichia coli, Klebsiella pneumoniae and other gramnegative bacteria in a hospital in Eastern Province, Saudi Arabia, Saudi Med J 2005;26(6):956-9. PMID: 15983682. PMID: 15701738
- Kim WB CK, Lee SW, Yang HJ, et al. Recent antimicrobial susceptibilities for uropathogenic Escherichia coli in patients with community acquired urinary tract infections: a multicenter study, Urogenit Tract Infect. 2017;12:28-34. https://doi.org/10.14777/uti.2017.12.1.28
- Kucheria R, Dasgupta P, Sacks SH, Khan MS, Sheerin NS. Urinary tract infections: new insights into a common problem, Postgrad Med J. 2005;81(952):83-6. https://doi.org/10.1136/pgmj.2004.023036
- Kunin CM. Urinary tract infections: detection, prevention, and management. 5th ed. Page 419. Baltimore: Williams & Wilkins; (1997). PMID: 22340940.
- Leblebicioglu H, Cakir N, Celen M, et al. Comparative activity of carbapenem testing (the COMPACT study) in Turkey, BMC Infect Dis. 2012;12:42. https://doi.org/10.1186/1471-2334-12-42
- Li B, Li M, Qu L, Wang M, Guo J. Prevalence and characteristics of extended-spectrum betalactamase-producing Klebsiella pneumoniae isolated from pediatric inpatients with respiratory tract infections at a teaching hospital in China, Scand J Infect Dis. 2014;46(3):200-3. https://doi.org/10.3109/00365548.2013.859393
- Nordmann P, Naas T, Poirel L. Global spread of carbapenemase-producing Enterobacteriaceae, Emerg Infect Dis. 2011;17(10):1791-8. https://doi.org/10.3201/eid1710.110655.PMID: 22000347.
- Öztürk İ, Avcı İY, Coşkun Ö, Gül HC, Eyigün CP. Birinci basamak sağlık kuruluşunda görev yapan hekimlerin sık görülen toplum kaynaklı enfeksiyonlardaki antibiyotik seçimleri ve bunu etkileyen faktörler, Fırat Tıp Derg. 2008;13(4):255-60.
- Morrissey I, Hackel M, Badal R, Bouchillon S, Hawser S, Biedenbach D. A review of ten years of the study for monitoring antimicrobial resistance Trends (SMART) from 2002 to 2011, Pharmaceuticals (Basel). 2013;6(11):1335-46. https://doi.org/10.3390/ph6111335
- Stultz JS, Doern CD, Godbout E. Antibiotic resistance in pediatric urinary tract infections, Curr Infect Dis Rep. 2016;18(12):40. https://doi.org/10.1007/s11908-016-0555-4 PMID: 27761778.
- Tonkic M, Goic-Barisic I, Punda-Polic V. Prevalence and antimicrobial resistance of extended-spectrum beta-lactamases-producing Escherichia coli and Klebsiella pneumoniae strains isolated in a university hospital in Split, Croatia, Int Microbiol. 2005;8(2):119-24. PMID: 16052460.
- Tosun Aİ, Demirci M, Yılmaz M, ve ark. İdrar yolu infeksiyonlarindan izole edilen Escherichia coli ve Klebsiella pneumoniae/suşlarının antimikrobiyal direnç oranlari, ANKEM Derg. 2016;30(1):1-6. https://doi.org/10.5222/ankem.2016.001
- Ulusal Antimikrobiyal Direnç Surveyans Sistemi, Türkiye Halk Sağlığı Kurumu, Sağlık Bakanlığı, Ankara. Erişim adresi: http://mikrobiyoloji.thsk. saglik.gov.tr/uamdss.html, Erişim Tarihi:22.04.2018
- Vardakas KZ, Legakis NJ, Triarides N, Falagas ME. Susceptibility of contemporary isolates to fosfomycin: a systematic review of the literature, Int J Antimicrob Agents. 2016;47(4):269-85.
- Weist K, Hogberg LD. ECDC publishes 2015 surveillance data on antimicrobial resistance and antimicrobial consumption in Europe, Euro Surveill 2016;21(46). https://doi.org/10.2807/1560-7917.ES.2016.21.46.30399 PMID: 27918266
Evaluation of Extended Spectrum Beta-lactamase Production Rates and Antibiotic Susceptibilities of Escherichia coli and Klebsiella pneumoniae Strains Isolated from Urine Cultures of Outpatients
Abstract
Urinary system infections (UTIs) are one of the most common diseases in the practice of infectious diseases. Gram-negative bacteria are responsible for 75–95 % of uncomplicated UTIs. Escherichia coli is the most frequently isolated microorganism in both complicated and uncomplicated UTIs. Among the gram-negative bacteria, the most frequently isolated pathogen after E.coli is Klebsiella pneumoniae. In E.coli and K.pneumoniae, the presence of extended-spectrum beta-lactamase (ESBL) enzyme is increasing over time. An increased resistance profile in community-acquired infections is an important problem in empirical antibiotic therapy selection, especially in primary care. In the current study, we aimed to help the selection of empirical antibiotic treatment by examining ESBL ratios and antibiotic resistance profiles in E. coli and K.pneumoniae isolated from urine cultures of patients admitted to polyclinic with complaints of the urinary system.
This study was carried out by retrospectively examining the urine cultures sent to the microbiology laboratory from polyclinic patients in Yozgat City Hospital, complaining infection of the urinary system. Between January 2017 and February 2018, 524 E.coli and 104 K.pneumoniae detected in urine culture were included in the study. Only one isolate for each patient was taken into study. Bacterial identification and antibiotic susceptibilities were performed using conventional methods and automated systems. The ESBL positivity rates of isolated E.coli and K.pneumoniae strains were 29.9 % and 28.8 %, respectively, and there was no statistically significant difference in the ESBL production (p=0.9). The most effective antibiotic for E.coli strains was meropenem (99 %) and the least effective antibiotic was ampicillin (42.6 %).
Ampicillin was not evaluated for K. pneumoniae strains because of its intrinsic resistance. The most effective antibiotic against K.pneumoniae was imipenem (98.9 %) and the least effective antibiotic for K.pneumoniae strains was nitrofurantoin (42.6 %). When ESBL positive isolates were evaluated, the lowest activity was found for ampicillin against E.coli strains and for cefuroxime against K.pneumoniae strains.
As reported in other studies undertaken in our country and in the world, there has been an increase in ESBL producing strains. It should be remembered that there are high resistance rates against trimethoprim and cephalosporins. It is also important that each region exhibits its own antibiotic resistance profile. The current antibiotic resistance data were obtained from microbiological analysis, we recommend further research on the clinical efficacy of the antibiotics against these strains.
Keywords
Escherichia coli extended-spectrum beta-lactamases Klebsiella pneumoniae urinary tract infection
References
- Ağca H. Escherichia coli ve Klebsiella pneumoniae suşlarının genişlemiş spektrumlu beta-laktamaz üretimleri ve antibiyotik duyarlılık oranları, DEÜ Tıp Fak Derg. 2011;25(3):169-73.
- Canton R, Novais A, Valverde A, et al. Prevalence and spread of extended-spectrum beta-lactamaseproducing Enterobacteriaceae in Europe, Clin Microbiolol Infect. 2008;14(Suppl 1):144-53.
- Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: Twenty-first Informational Supplement M 100-S21. CLSI, Wayne, PA, USA, (2011).
- Del Carmen Rodriguez M, Vera DE, RamirezRonda CH, Saavedra S. Phenotypic confirmation of extended-spectrum B-lactamases (ESBL) in clinical isolates of Escherichia coli and Klebsiella pneumoniae at the San Juan Veterans Affairs Medical Center, P R Health Sci J. 2004;23(3):207-15. PMID: 15631176.
- Ece GT, Tunçel BM. Bir üniversite hastanesine gönderilen idrar kültürlerinde üreyen izolatların dağılımı ve antimikrobiyal duyarlılık profilinin incelenmesi, Ege Tıp Derg. 2013;52(3):136-40.
- European Committee on Antimicrobial Susceptibility Testing Breakpoint tables for interpretation of MICs and zone diameters Version 7.1, Erişim Adresi: http://www.eucast.org/fileadm i n / s r c / m e d i a / P D F s / E U C A S T _ f i l e s /Breakpoint_tables/v_7.1_Breakpoint_Tables.pdf. Erişim Tarihi: 22.04.2018
- Falagas ME, Vouloumanou EK, Togias AG, et al. Fosfomycin versus other antibiotics for the treatment of cystitis: a meta-analysis of randomized controlled trials, J Antimicrob Chemother 2010;65(9):1862-77. https://doi.org/10.1093/jac/dkq237PMID: 20587612.
- Ferraro G, Ambrosi G, Bucci L, Palmieri R, Palmieri G. Fosfomycin trometamol versus norfloxacin in the treatment of uncomplicated lower urinary tract infections of the elderly, Chemotherapy 1990;36(Suppl 1):46-9. https://doi.org/10.1159/000238817PMID: 2085990.
- Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs, Dis Mon. 2003;49(2):53-70. PMID: 12601337. https://doi.org/10.1016/S0002-9343(02)01054-9
- Galindo-Mendez M. Molecular characterization and antimicrobial susceptibility pattern of extended-spectrum beta-lactamase-producing Escherichia coli as cause of community acquired urinary tract infection, Rev Chilena Infectol. 2018;35(1):29-35. https://doi.org/10.4067/s0716-10182018000100029
- Garau J. Other antimicrobials of interest in the era of extended-spectrum beta-lactamases: fosfomycin, nitrofurantoin and tigecycline, Clin Microbiol Infect. 2008;14(Suppl 1):198-202. https://doi.org/10.1111/j.1469-0691.2007.01852.x
- Gündem NS, Çıkman A, Gülhan B. İdrar kültürlerinden izole edilen Escherichia coli ve Klebsiella spp. suşlarının genişlemiş spektrumlu betalaktamaz (GSBL) üretimi ve antibiyotik direnci, JCEI 2013;4(1):56-62. https://doi.org/10.5799/ahinjs.01.2013.01.0234
- Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases, Clin Infect Dis 2011;52(5):e103-20. https://doi.org/10.1093/cid/ciq257.PMID: 21292654.
- Hooton TM, Pacita L, Roberts MS, et al. Voided Midstream Urine Culture and Acute Cystitis in Premenopausal Women, N Engl J Med. 2013;369(20):1883-91. PMID: 24224622 https://doi.org/10.1056/NEJMoa1302186
- Hooton TM. Clinical practice. Uncomplicated urinary tract infection, N Engl J Med. 2012; 366(11):1028-37. PMID: 22417256. https://doi.org/10.1056/NEJMcp1104429
- Kader AA, Angamuthu K. Extended-spectrum beta-lactamases in urinary isolates of Escherichia coli, Klebsiella pneumoniae and other gramnegative bacteria in a hospital in Eastern Province, Saudi Arabia, Saudi Med J 2005;26(6):956-9. PMID: 15983682. PMID: 15701738
- Kim WB CK, Lee SW, Yang HJ, et al. Recent antimicrobial susceptibilities for uropathogenic Escherichia coli in patients with community acquired urinary tract infections: a multicenter study, Urogenit Tract Infect. 2017;12:28-34. https://doi.org/10.14777/uti.2017.12.1.28
- Kucheria R, Dasgupta P, Sacks SH, Khan MS, Sheerin NS. Urinary tract infections: new insights into a common problem, Postgrad Med J. 2005;81(952):83-6. https://doi.org/10.1136/pgmj.2004.023036
- Kunin CM. Urinary tract infections: detection, prevention, and management. 5th ed. Page 419. Baltimore: Williams & Wilkins; (1997). PMID: 22340940.
- Leblebicioglu H, Cakir N, Celen M, et al. Comparative activity of carbapenem testing (the COMPACT study) in Turkey, BMC Infect Dis. 2012;12:42. https://doi.org/10.1186/1471-2334-12-42
- Li B, Li M, Qu L, Wang M, Guo J. Prevalence and characteristics of extended-spectrum betalactamase-producing Klebsiella pneumoniae isolated from pediatric inpatients with respiratory tract infections at a teaching hospital in China, Scand J Infect Dis. 2014;46(3):200-3. https://doi.org/10.3109/00365548.2013.859393
- Nordmann P, Naas T, Poirel L. Global spread of carbapenemase-producing Enterobacteriaceae, Emerg Infect Dis. 2011;17(10):1791-8. https://doi.org/10.3201/eid1710.110655.PMID: 22000347.
- Öztürk İ, Avcı İY, Coşkun Ö, Gül HC, Eyigün CP. Birinci basamak sağlık kuruluşunda görev yapan hekimlerin sık görülen toplum kaynaklı enfeksiyonlardaki antibiyotik seçimleri ve bunu etkileyen faktörler, Fırat Tıp Derg. 2008;13(4):255-60.
- Morrissey I, Hackel M, Badal R, Bouchillon S, Hawser S, Biedenbach D. A review of ten years of the study for monitoring antimicrobial resistance Trends (SMART) from 2002 to 2011, Pharmaceuticals (Basel). 2013;6(11):1335-46. https://doi.org/10.3390/ph6111335
- Stultz JS, Doern CD, Godbout E. Antibiotic resistance in pediatric urinary tract infections, Curr Infect Dis Rep. 2016;18(12):40. https://doi.org/10.1007/s11908-016-0555-4 PMID: 27761778.
- Tonkic M, Goic-Barisic I, Punda-Polic V. Prevalence and antimicrobial resistance of extended-spectrum beta-lactamases-producing Escherichia coli and Klebsiella pneumoniae strains isolated in a university hospital in Split, Croatia, Int Microbiol. 2005;8(2):119-24. PMID: 16052460.
- Tosun Aİ, Demirci M, Yılmaz M, ve ark. İdrar yolu infeksiyonlarindan izole edilen Escherichia coli ve Klebsiella pneumoniae/suşlarının antimikrobiyal direnç oranlari, ANKEM Derg. 2016;30(1):1-6. https://doi.org/10.5222/ankem.2016.001
- Ulusal Antimikrobiyal Direnç Surveyans Sistemi, Türkiye Halk Sağlığı Kurumu, Sağlık Bakanlığı, Ankara. Erişim adresi: http://mikrobiyoloji.thsk. saglik.gov.tr/uamdss.html, Erişim Tarihi:22.04.2018
- Vardakas KZ, Legakis NJ, Triarides N, Falagas ME. Susceptibility of contemporary isolates to fosfomycin: a systematic review of the literature, Int J Antimicrob Agents. 2016;47(4):269-85.
- Weist K, Hogberg LD. ECDC publishes 2015 surveillance data on antimicrobial resistance and antimicrobial consumption in Europe, Euro Surveill 2016;21(46). https://doi.org/10.2807/1560-7917.ES.2016.21.46.30399 PMID: 27918266
Details
| Primary Language | Turkish |
|---|---|
| Subjects | Clinical Microbiology |
| Journal Section | Research Articles |
| Authors | |
| Publication Date | December 30, 2018 |
| Published in Issue | Year 2018 Volume: 32 Issue: 3 |
This work is licensed under a https://creativecommons.org/licenses/by-nc-nd/4.0/ license.