Tuberculosis and Respiratory Diseases

  • 제60권2호
  • /
  • Pages.228-234
  • /
  • 2006
  • /
  • 1738-3536(pISSN)
  • /
  • 2005-6184(eISSN)
대한결핵및호흡기학회 (The Korean Academy of Tuberculosis and Respiratory Diseases)
권호 표지

객담에서 Carbapenem 내성 Acinetobacter baumannii가 동정된 중환자실 환자의 임상적 특징

Clinical Characteristics of Intensive Care Unit Patients with Carbapenem Resistant Acinetobacter Baumannii Isolated from Sputum

  • 이성원 (강원대학교 의과대학 내과학교실 및 강원대학교병원 임상의학연구소) ;
  • 조희숙 (강원대학교 의과대학 예방의학교실 및 강원대학교병원 임상의학연구소) ;
  • 김우진 (강원대학교 의과대학 내과학교실 및 강원대학교병원 임상의학연구소)
  • Lee, Sung Won (Department of Internal Medicine, College of Medicine, Kangwon National University and Clinical Research Institute of Kangwon National University Hospital) ;
  • Jo, Heui Sug (Department of Preventive Medicine, College of Medicine, Kangwon National University and Clinical Research Institute of Kangwon National University Hospital) ;
  • Kim, Woo Jin (Department of Internal Medicine, College of Medicine, Kangwon National University and Clinical Research Institute of Kangwon National University Hospital)
  • 투고 : 2005.09.01
  • 심사 : 2006.01.26
  • 발행 : 2006.02.28
PDF 다운로드
⟨ 이전 논문 다음 논문 ⟩

초록

연구배경 : A. baumannii는 중환자실내의 원내감염의 중요 원인균으로 인식되고 있으며, 원내 폐렴, 요로 감염증, 균혈증 등을 일으킨다. 현재 이 균의 다약제 내성이 문제되고 있으며 특히 carbapenem에 내성을 보이고 있는 것이 가장 큰 문제가 되고 있다. 이 연구의 목적은 중환자실 환자의 객담에서 배양된 A. baumannii 중 carbapenem 내성군과 감수성군 두 군으로 나누어 위험인자를 알아보고 임상적 특징을 비교 및 분석하는 것이다. 방 법 : 2003년 1월 1일부터 2003년 12월 31일까지 강원대학교 중환자실에 입원한 성인 환자들 중 객담 배양 검사상 A. baumannii가 한 번이라도 검출된 환자들을 대상으로 챠트 기록을 통한 후향적 분석을 하였다. 위험인자로 연령, 성별, APACHE II score, 동반질환, 사용한 항생제, 재원기간, 중환자실 재원기간, Clinical Pulmonary Infection Score, 인공호흡기 여부를 평가하였다. 결 과 : 총 49명으로 A. baumannii에 대한 carbapenem 감수성군은 23명 내성군은 26명이었다. 단일변량분석에서는 신장 질환, 이전의 aminoglycoside 및 carbapenem 사용력이 통계적인 의미를 보였고 다변량분석에서는 이전의 aminoglycoside 사용력은 carbapenem 내성과 음의 상관관계를(p=0.026; OR, 0.18; CI, 0.04 to 0.82), 이전의 carbapenem 사용력은 carbapenem 내성과 양의 상관관계를(p=0.024; OR, 8.17; CI 1.32 to 50.68) 보여주었다. 사망률에서는 양 군에서 유의한 차이를 보이지 않았다(30 vs 42%, P=0.39). 결 론 : Carbapenem 내성 A. baumannii의 발생의 위험인자로 이전의 aminoglycoside와 carbapenem 사용력이 있으며 carbapenem 사용 시 A. baumannii의 carbapenem 내성정도가 증가함을 볼 수 있다.

Background : Acinetobacter baumannii is an important pathogen associated with nosocomial infections in intensive care units, and is responsible for nosocomial pneumonia, UTI, bacteremia, etc. The main concern is that this pathogen is often resistant to many antimicrobial agents, particularly to carbapenem. This study compared the clinical those of ICU admitted patients with the carbapenem resistant A. baumannii isolated from the sputum with characteristics of patients with carbapenem sensitive A. baumannii. Methods : A total of 49 patients with A. baumannii from a sputum culture who were admitted to the ICU from January to December 2003 were enrolled in this study. This study evaluated the demographic variables, mortality, APACHE II score, comorbidity, antibiotics used, hospital and ICU stay, Clinical Pulmonary Infection Score, and mechanical ventilation. A retrospective analysis was made by a review of the patients' medical records. Results : Carbapenem sensitive and resistant A. baumannii was isolated from 23 patients and 26 patients respectively. Univariate analysis revealed renal disease, the use of carbapenem and aminoglycoside to be statistically significant factors for carbapenem resistance. Multivariate analysis revealed carbapenem use(p=0.024; OR, 8.17; CI 1.32 to 50.68) to be positively associated with carbapenem resistance, and aminoglycoside use(p=0.026; OR, 0.18; CI, 0.04 to 0.82) to be negatively associated with carbapenem resistance. There was no significant difference in mortality between the carbapenem sensitive and resistant group(30 vs 42%. P=0.39). Conclusion : The occurrence of carbapenem resistant A. baumannii is positively associated with carbapenem use and negatively associated with aminoglycoside use. Carbapenem resistance in the sputum culture did not affect the mortality rate.

키워드

참고문헌

  1. Zarrilli R, Crispino M, Bagattini M, Barretta E, Popolo AD, Triassi M, et al. Molecular epidemiology of sequential outbreaks of Acinetobacter baumannii in an Intensive Care Unit shows the emergence of carbapenem resistance. J Clin Microbiol 2004;42:946-53 https://doi.org/10.1128/JCM.42.3.946-953.2004
  2. Maniatis AN, Pournaras S, Orkopoulou S, Tassios PT, Legakis NJ. Multiresistant Acinetobacter baumannii isolates in intensive care units in Greece. Clin Microbiol Infect 2003;9:547-53 https://doi.org/10.1046/j.1469-0691.2003.00558.x
  3. Cisneros JM, Rodriguez BJ. Nosocomial bacteremia due to Acinetobacter baumannii: epidemiology, clinical features and treatment. Clin Microbiol Infect 2002;8:687-93 https://doi.org/10.1046/j.1469-0691.2002.00487.x
  4. Looveren MV, Goossens H. Antimicrobial resistance of Acinetobacter spp. in Europe. Clin Microbiol Infect 2004;10:684-704 https://doi.org/10.1111/j.1469-0691.2004.00942.x
  5. Higgins PG, Wisplinghoff H, Stefanik D, Seifert H. In Vitro Activities of the B-Lactamase Inhibitors Clavulanic Acid, Sulbactam, and Tazobactam Alone or in Combination with B-Lactams against Epidemiologically Characterized Multidrug-Resistant Acinetobacter baumannii Strains. Antimicrob Agents Chemother 2004;48:1586-92 https://doi.org/10.1128/AAC.48.5.1586-1592.2004
  6. Turner PJ, Greenhalgh JM. The activity of meropenem and comparators against Acinetobacter strains isolated from European hospitals, 1997-2000. Clin Microbiol Infect 2003;9:563-7 https://doi.org/10.1046/j.1469-0691.2003.00591.x
  7. Choi JY, Park YS, Cho CH, Park YS, Shin SY, Song YG, et al. Synergic in-vitro activity of imipenem and sulbactam against Acinetobacter baumannii. Clin Microbiol Infect 2004;10:1098-101 https://doi.org/10.1111/j.1469-0691.2004.00987.x
  8. Levin AS. Multiresistant Acinetobacter infections: a role for sulbactam combinations in overcoming an emerging worldwide problem. Clin Microbiol Infect 2002;8:144-53 https://doi.org/10.1046/j.1469-0691.2002.00415.x
  9. Corbella X, Montero A, Pujol M, Dominguez MA, Ayats J, Agrerich MJ, et al. Emergence and Rapid Spread of Carbapenem Resistance during a Large and Sustained Hospital Outbreak of Multiresistant Acinetobacter baumannii. J Clin Microbiol 2000;38:4086-95
  10. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985;13:818-29 https://doi.org/10.1097/00003246-198510000-00009
  11. Lee JH, Cheon SC, Jung SH, Phyun LH, Jang MZ, Lee YG, et al. Clinical usefulness of ClinicalPul monary Infection Score of ICU patients with Sputum Culture positive for Multi-drug resistant Acinetobacter baumannii. Tuberc Respir Dis 2003; 55:579-88
  12. Paterson DL. Looking for Risk Factors for the Acquisition of Antibiotic Resistance: A 21st-Century Approach. Clin Infect Dis 2002;34:1564-7 https://doi.org/10.1086/340532
  13. Lee SO, Kim NJ, Choi SH, Kim TH, Chung JW, Woo JH, et al. Risk factors for acquisition of imipenem-resistant Acinetobacter baumannii: a case-control study. Antimicrob Agents Chemother 2004;48:224-8 https://doi.org/10.1128/AAC.48.1.224-228.2004
  14. Mulin B, Talon D, Viel JF, Vincent C, Leprat R, Thouverez M et al. Risk factors for nosocomial colonization with multiresistant Acinetobacter baumannii. Eur J Clin Microbiol Infect Dis 1995;14:569-76
  15. Scerpella EG, Wanger AR, Armitige L, Anderlini P, Ericsson CD. Nosocomial outbreak caused by a multiresistant clone of Acinetobacter baumannii: results of the case-control and molecular epidemiologic investigations. Infect Control Hosp Epidemiol 1995;16:92-7 https://doi.org/10.1086/647063
  16. Husni RN, Goldstein LS, Arroliga AC, Hall GS, Fatica C, Stoller JK et al. Risk factors for an outbreak of multi-drug-resistant Acinetobacter nosocomial pneumonia among intubated patients. Chest 1999;115:1378-82 https://doi.org/10.1378/chest.115.5.1378
  17. Koeleman JG, Parlevliet GA, Dijkshoorn L, Savelkoul PH, Vandenbroucke-Grauls CM. Nosocomial outbreak of multi-resistant Acinetobacter baumannii on a surgical ward: epidemiology and risk factors for acquisition. J Hosp Infect 1997;37:113-23 https://doi.org/10.1016/S0195-6701(97)90181-X
  18. Lortholary O, Fagon JY, Hoi AB, Slama MA, Pierre J, Giral P et al. Nosocomial acquisition of multiresistant Acinetobacter baumannii: risk factors and prognosis. Clin Infect Dis 1995;20:790-6 https://doi.org/10.1093/clinids/20.4.790
  19. Doi Y, Wachino JI, Yamane K, Shibata N, Yagi T, Shibayama K, et al. Spread of Novel Aminoglycoside Resistance Gene aac(6)-Iad among Acinetobacter Clinical Isolates in Japan. Antimicrob Agents Chemother 2004;48:2075-80 https://doi.org/10.1128/AAC.48.6.2075-2080.2004
  20. Over U, Gur D, Unal S, Miller GH. The changing nature of aminoglycoside resistance mechanisms and prevalence of newly recognized resistance mechanisms in Turkey. Clin Microbiol Infect 2001;7:470-8 https://doi.org/10.1046/j.1198-743x.2001.00284.x
  21. Gold HS, Moellering RC. Antimicrobial-drug resistance. N Engl J Med 1996;335:1445-53 https://doi.org/10.1056/NEJM199611073351907
  22. Bernabeu-Wittel M, Pichardo C, Garcia-Curiel A, Pachon-Ibanez ME, Ibanez-Martinez J. Jimenez-Mejias ME, et al. Pharmacokinetic /pharmacodynamic assessment of the in-vivo efficacy of imipenem alone or in combination with amikacin for the treatment of experimental multiresistant Acinetobacter baumannii pneumonia. Clin Microbiol Infect 2005;11:319-25 https://doi.org/10.1111/j.1469-0691.2005.01095.x
  23. Garnacho J, Sole-Violan J, Sa-Borges M, Diaz E, Rello J. Clinical impact of pneumonia caused by Acinetobacter baumannii in intubated patients: A matched cohort study. Crit Care Med 2003;31;2478-82 https://doi.org/10.1097/01.CCM.0000089936.09573.F3
  24. Bregeon F, Ciais V, Carret V, Gregoire R, Saux P, Gainnier M et al. Is ventilator-associated pneumonia an independent risk factor for death? Anesthesiology 2001;94:554-60 https://doi.org/10.1097/00000542-200104000-00005
  25. Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C. Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 1993;94:281-8 https://doi.org/10.1016/0002-9343(93)90060-3
  26. Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002;122:2115-21 https://doi.org/10.1378/chest.122.6.2115
  27. Bercault N, Boulain T. Mortality rate attributable to ventilator-associated nosocomial pneumonia in an adult intensive care unit: a prospective case-control study. Crit Care Med 2001;29:2303-9 https://doi.org/10.1097/00003246-200112000-00012
  28. Kollef MH. What is ventilator-associated pneumonia and why is it important? Respir Care 2005;50:714-24
  29. Del Mar Tomas M, Cartelle M, Pertega S, Beceiro A, Llinares P, Canle D et al. Hospital outbreak caused by a carbapenem-resistant strain of Acinetobacter baumannii: patient prognosis and risk-factors for colonisation and infection. Clin Microbiol Infect 2005;11:540-6 https://doi.org/10.1111/j.1469-0691.2005.01184.x
  30. Michalopoulos AS, Tsiodras S, Rellos K, Mentzelopoulos S, Falagas ME. Colistin treatment in patients with ICU-acquired infections caused by multiresistant gram-negative bacteria: the renaissance of an old antibiotic. Clin Microbiol Infect 2005;11:115-21 https://doi.org/10.1111/j.1469-0691.2004.01043.x