Clinical and Experimental Pediatrics

The Korean Pediatric Society (대한소아청소년과학회)
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Molecular-epidemiologic study on outbreak of colonization by extended spectrum β-lactamase producing Klebsiella pneumoniae in neonatal intensive care unit

신생아 중환자실에서 extended spectrum β-lactamase를 생성하는 Klebsiella pneumoniae 집단 보균 발생의 분자 역학적 조사 및 추적관찰

  • Jun, Nu-Lee (Division of Neonatology, Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Kim, Mi-Na (Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Jeong, Jae-Sim (Department of Hospital Infection Control, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Kim, Yang-Soo (Department of Hospital Infection Control, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Kim, Ellen Ai-Rhan (Division of Neonatology, Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Kim, Ki-Soo (Division of Neonatology, Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Pi, Soo-Young (Division of Neonatology, Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine)
  • 전누리 (울산대학교 의과대학 서울아산병원 신생아과) ;
  • 김미나 (울산대학교 의과대학 서울아산병원 진단검사의학과) ;
  • 정재심 (울산대학교 의과대학 서울아산병원 감염관리팀) ;
  • 김양수 (울산대학교 의과대학 서울아산병원 감염관리팀) ;
  • 김애란 (울산대학교 의과대학 서울아산병원 신생아과) ;
  • 김기수 (울산대학교 의과대학 서울아산병원 신생아과) ;
  • 피수영 (울산대학교 의과대학 서울아산병원 신생아과)
  • Received : 2005.09.01
  • Accepted : 2005.10.25
  • Published : 2006.02.15
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Abstract

Purpose : The aims of this study included assessment of molecular-epidemiologic features during an outbreak of colonization of extended spectrum ${\beta}$-lactamase producing Klebsiella pneumoniae(ESBL-KPN) and re-evaluation of their colonized status one year later. Methods : Rectal swab cultures for ESBL-KPN from all hospitalized infants and newly admitted infants were obtained during the outbreak of colonization from July to December, 2000. The pattern of XbaI-digested chromosomal DNA of isolates were analyzed by pulsed-field gel electrophoresis. Weekly rectal swab cultures were obtained during the outbreak until patients were either discharged or decolonized. Patients discharged after being colonized had follow up stool cultures a year later. Results : A total of 80 patients(28.5 percent) were colonized. Of those, 53 whose pulsed-field gel electrophoresis(PFGE) was possible only once, were ESBL-KPN grouped into six cluster clones and 10 single clones : 28 patients(52.8 percent) were colonized with type A, the most common clone, followed by type B in 11 patients(20.8 percent). Of those 12 patients in whom serial PFGE was done more than twice, type A was predominant. Narrowed-down in strains occurred from types A, B, C, D and three single clones at initiation of the study into types A and type B after three months of strict infection control. Among 75 patients(93.7 percent) who were sent home after being colonized, 30 patients were re-called for stool cultures a year later : All of them were decolonized. Conclusion : This study demonstrates the importance of infection control as the diversity of ESBL-KPN strains could be narrowed into fewer strains. Colonization of ESBL-KPN could be reversed upon return to the community.

목 적 : 2000년 6월과 7월에 본원 신생아 중환자실에서는 ESBL 생성 K. pneumoniae에 의한 패혈증이 집단 발생하여 전체 환아에 대한 보균 상태를 파악하고 감염관리를 위해 감시배양을 실시하였다. 당시 집단 보균 상태임을 발견하여 보균자에 대한 격리를 실시한 결과 집단보균을 해결할 수 있었으나 대부분의 환아가 보균 상태로 퇴원하였다. ESBL 생성 K. pneumoniae는 대변 내 균이 장착되어서 입원 환아들간에 집단 감염을 일으킬 수 있으며, 이러한 균주에 의한 집단감염은 치료와 예후에 중요한 인자로 작용될 것으로 생각된다. 이에 저자들은 집단보균 발생시 분리된 ESBL 생성 K. pneumoniae의 분자 역학적 특징과 보균환아들의 추적관찰 결과를 알아보고자 본 연구를 시행하였다. 방 법 : 2000년 7월 28일부터 12월 30일까지 입원환아를 대상으로 직장내 도말법으로 감시배양검사를 시행하였다. 감시배양검사는 재원환아들에서 1주 간격으로 시행하였고, 신환은 입원 당일에 시행하였다. 균주의 형별 검사를 위해서 Pulsed-field gel electrophoresis(PFGE)를 시행하였고, 보균 상태로 퇴원했던 환아들은 외래에서 대변 배양검사로 추적 관찰하였다. 결 과 : 감시 배양기간 중 총 80명(28.5%)의 환아에서 보균이 확인되었고, 퇴원시 5명(6.3%)에서 음성이 확인되었다. PFGE를 시행한 65명의 타이핑 결과, 일회의 PFGE를 시행한 53명에서 분리된 균주의 염색체 유전자 분획양상은 집단클론 6가지, 단독클론 10가지형으로 분류되었고, 집단 클론 중 A형이 28명(52.8%)으로 가장 많았고, B형이 11명(20.8%), C, D, F, G형이 각각 1명(1.9%)이었다. 2회 이상 검사를 시행한 12명 중 초기검사에서는 A형이 10명(83.3%)으로 월등히 많았고 B형은 2명(16.7%)이었으며, 추적검사에서 분획 양상이 변화된 경우는 6명(50%)이었고, 이들은 A나 B로 변화된 경우가 각각 2명(33.3%)이었다. 변화되지 않은 6명(50%)은 모두 A형으로 남아 있었다. 월별 PFGE 양상은 처음 배양시 집단클론 A, B, C, D형 4가지와 단독클론 세 가지형이었으나 감염 관리를 하면서 11월부터 집단클론 A, B 두 가지형으로 나타나는 양상을 보였고, A형이 더 우세하였다. 보균된 상태로 퇴원한 75명 중 외래 추적관찰이 가능했던 30명을 대상으로 대변 배양검사를 시행한 결과 모두 음성이 확인되었다. 결 론 : 다양한 클론의 균주에 의한 집단보균 상태는 감염 관리를 하면서 단일 클론으로 변화하는 양상을 보였고, A형이 우세한 것으로 보아 집단 보균을 일으킨 유형 중 주 집단 클론은 A형이었음을 알 수 있었다. ESBL 생성 K. pneumoniae 보균 상태는 중환자실내에 입원기간 중에는 거의 지속되지만, 지역사회로 복귀하면 전부 해제되는 것으로 보인다.

Keywords

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