İdrar Yolu Enfeksiyonlarinin Ampirik Tedavisinde İlk Seçenek Antimikrobikler Neler Olmalı?

Year 2016, Volume: 16 Issue: 1, 0 - 0, 04.03.2016

Birsen Özdem , Ayşegül Gözalan , Nevreste Çelikbilek , Fisun Kırca , Sibel Aydoğan Ziya Cibali Açıkgöz

https://doi.org/10.17098/amj.61562

Abstract

 

Amaç: Çalışmamızın amaçları, 2011-2012 tarihleri arasında, alt üriner sistem enfeksiyonu (ÜSE) tanılı poliklinik hastalarından izole edilen mikroorganizmaların dağılımı, antibiyotik direnç profillerinin araştırılması ve uygun ampirik tedavi seçeneklerinin belirlenmesidir.

Materyal ve Metot: 2011–2012 tarihleri arasında, hastanemiz polikliniklerinden alt ÜSE ön tanısı ile gönderilen 14096 idrar örneğinin kültür / antibiyogram sonuçları retrospektif olarak değerlendirildi. Tekrarlayan üremeler hariç tutularak toplam 2005 örnekteki üremeler değerlendirmeye alındı. Kültür ve identifikasyon testleri konvansiyonel/yarı otomatik ve otomatik yöntemlerle yapıldı. Antibiyotik duyarlılık testleri CLSI (Clinical Laboratory Standarts Institute) önerileri doğrultusunda Kirby-Bauer disk difüzyon yöntemiyle gerçekleştirildi.

Bulgular: Örneklerin %83,7’sinde Enterobacteriaceae üyeleri üredi.  Bunların 1287’si (%64,2) E.coli; 238’i (%11,9) K.pneumoniae idi. Toplam 67 (%3,3) örnekte P.aeruginosa üredi. Gram-pozitif üremelerin oranı; 55’i (%2,7) metisiline dirençli koagülaz negatif stafiolokok, 55’i (%2,7) E.faecalis, 49’u (%2,4) S.agalactia v.b. olmak üzere %12,86 idi. Genişlemiş spektrumlu beta laktamaz prevalansı E.coli izolatlarında %23,2; K.pneumonia izolatlarında %25,4 olarak belirlendi. Gerek Gram-pozitif, gerekse Gram-negatif izolatlarda, oral kullanımı olan antimikrobikler içinde nitrofurantoin (NF) en düşük direnç oranına sahipti (sırasıyla %2,7 ve %12,1). Öte yandan Gram-pozitif bakteriler için ampisilin (%6,3), Gram-negatif bakteriler için ise sefuroksim (%25,9) en düşük direnç oranlarına sahip diğer oral tedavi seçenekleri olarak belirlendi.

Sonuç: Yetişkin yaş grubundaki poliklinik hastalarımızın alt ÜSE enfeksiyonlarında NF en geniş antibakteriyel etki spektrumuna sahip oral ilaç olarak öne çıkmaktadır. Ampisiline duyarlı Gram-pozitif izolatların (Enterokokspp. hariç) sefuroksime de duyarlı olacağı düşünülürse, ikinci en geniş spektrumlu oral ilacın sefuroksim olduğu söylenebilir. Sanford, IDSA v.b. tedavi kılavuzlarında NF, trimetoprim sulfametoksazol (TMP-SXT), ilk veya ikinci tedavi seçeneği olarak önerilmekle birlikte çalışmamızda bu oran %35 düzeyinde bulunduğu için TMP-SXT, hasta grubumuz için uygun bir tedavi seçeneği gibi görünmemektedir.

Keywords

İdrar yolu enfeksiyonu, Antibiyotik direnci; Enterobactericeae; ESBL; Ampirik tedavi

Which Antibiotics Should be the First Choice for Empiric Therapy of Urinary Tract Infections?

Abstract

 

Objectives: The aims of the study were to investigate the distribution and the antibiotic resistance profiles of the microorganisms isolated from outpatients with lower urinary tract infection (UTI) during 2011-2012 period and to determine the most appropriate empirical therapy choices.

Materials and Methods: Culture and susceptibility test results of 14.096 urine samples sent from outpatient clinics with presumptive lower UTI diagnosis in the last year (2011-2012) were reviewed. Excluding the duplications, totally 2005 isolates were evaluated. Culture and identification tests were done by conventional/semi-automatic and automatic methods. Antibiotic susceptibility tests were performed by Kirby-Bauer disc diffusion method according to the recommendations of CLSI (Clinical Laboratory Standarts Institute).

Results: Enterobacteriaceae spp. were isolated from 82.3% of the urine samples; 1287 (64.2%) Escherichia coli and 238 (11.9%) Klebsiella pneumonia, 67 (3.3%) Pseudomonas aeruginosa was cultivated. Totally 12.9% of the samples yielded Gram-positive bacteria including 55 (2.8%) meticillin resistant coagulase negative staphylococci, 55 (2.8%) Enterococcus faecalis and 49 (2.4%) Streptococcus agalactiae. The extended spectrum beta-lactamase (ESBL) prevalence was 23.2% in E.coli and 25.4% in K.pneumoniae. Among oral antibiotics tested, nitrofurantoin (NF) had the lowest resistance rates for both Gram-positive and Gram-negative isolates with 2.7% and 12.1%, respectively.  Ampicillin for Gram-positives and Cefuroxim for Gram-negatives were other oral drugs with the lowest resistance rates with 6.3% and 25.9%, respectively.

Conclusion: NF appears as the most effective oral drug for adult outpatients with UTI. Cefuroxim can be considered as the second effective choice because ampicillin-sensitive Gram-positive isolates (except Enterococcus spp) would also be sensitive to it. NF and trimethoprim-sulfamethoxazole (TMP-SMX) is suggested as first or second choice in UTI treatment in antimicrobial therapy guidelines like Sanford and IDSA. However, TMP-SMX resistance was found 35% in our population; consequently it is not a suitable option for our patients.

Keywords

Urinary tract infection, Antibiotic resistance; Enterobactericeae; ESBL; Empirical treatment

References

• Ağuş N, Yılmaz ÖN, Türken M, Akgüre N, Küçükkaya D. Sefdinir susceptibility of Gram-negative microorganisms isolated from urinary tract infection. Tepecik Eğit Hast Der 2009;19:8-11.
• Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing, 17th Informational Supplement, 2007; CLSI/NCCLS Document M100-S17, Wayne, PA.
• Clinical and Laboratory Standarts Institude. Performance Standarts for Antimicrobial Susceptibility Testing. 23th Informational Supplement 2013; CLSI Document M100-S23, Wayne, PA.
• Arman D, Ağalar C, Dizbay M et al. Community acquired lower urinary tract infections in primary care: Causative agents and antimicrobial susceptibility. Mediterr J Infect Microb Antimicrob 2012;1:1-8.
• Kandemir Ö, Akdağ A, Kurt AÖ. Antibiotic susceptibility of bacterial strains isolated from patients with community acquired urinary tract infections in Mersin. TAF Preventive Medicine Bulletin 2012;11:589-98.
• Altoparlak Ü, Özbek A, Aktaş F. Antibiotic susceptibility of Gram-negative bacteria isolated from urinary tract infections. Türk Mikrobiyol Cem Derg 2002;32:167-73.
• Köksaldı MV, Tutanç M, Arıca V, Arıca S, Ay B. Susceptibility of uropathogen Escherichia coli strains to commonly used antibacterial
• agents in urinary tract infections. ANKEM Derg 2010;24:198-201.
• Sharma I, Paul D. Prevalence of community acquired urinary tract infections in silchar medical college, Assam, India and its antimicrobial susceptibility profile. Indian J Med Sci 2012;66:273-9.
• Ghosh AN, Bhatta DR, Ansari MT, Tiwari HK, Mathuria JP, Supram HS, et al. Application of WHONET in the antimicrobial resistance surveillance of uropathogens : A first user experience from Nepal. J Clin Diagn Res 2013;7:845-848.
• Mahesh E, Medha Y, Indumathi VA, et al. Community-acquired urinary tract infection in the elderly. BJMP 2011;4:a406.
• Magliano E, Grazioli V, Deflorio L, Leuci AI, Mattina R, Romano P, et al. Gender and age-dependent etiology of community-acquired urinary tract infections. The Scientific World Journal 2012; http://dx.doi.org/10.1100/2012/349597 .
• Bayram Y, Eren H, Berktaş M. Distrubution of bacterial pathogens in urine samples and resistance patterns of ESBL positive and negative Escherichia coli isolates against fosfomycin and other antimicrobials. ANKEM Derg 2011;25:232-6.
• Sağlam HS, Öğütlü A, Demiray V, Karabay O. The role of Escherichia coli’ s in community acquired urinary infections and developing antibiotic resistance. NOBEL MED 2012;8:67-71.
• Deveci Ö, Yula E, Tekin A. Frequency of extended spectrum beta-lactamase and resistance to Antibiotics in Escherichia coli strains isolated from urinary cultures. J Clin Exp Invest 2010;1:182-6.
• Aykan ŞB, Çiftçi İH. Antibiotic resistance patterns of Escherichia coli strains isolated from urine cultures in Turkey: A meta-analysis. Mikrobiyol Bul 2013;47:603-18.
• Gözel MG, Elaldı N, Korgalı E, et al. Antimicrobial susceptibility and frequency of extended spectrum beta-lactamase (ESBL) of Escherichia coli strains isolated from community acquired and nosocomial infections. Flora 2012;17:75-81.
• Karlowsky JA, Hoban DJ, DeCorby MR, Laing NM, Zhanel GG. Fluoquinolone-resistant urinary isolates of Escherichia coli from outpatients are frequently multidrug resistant: Results from the North Amerikan urinary tract infection collaborative alliance-quinolone resistance study. Antimicrob Agents Chemother 2006;50:2251-4.
• Bouchillon S, Hoban DJ, Badal R, Hawser S. Fluoroquinolone resistance among Gram-negative urinary tract pathogens: global Smart Program result 2009-2010. The Open Microbiology Journal 2012;6:74-8.
• Hooton TM. Uncomplicated urinary tract infection. NEJM 2012;366:1028-1037.
• McKinnell JA, Stollenwerk NS, Jung CW, Miller LG. Nitrofurantoin compares favorably to recommended againts as empirical treatment of uncomplicated urinary tract infections in a decision and cost analysis. Mayo Clin Proc 2011;86:480-8.
• Rudy M, Nowakowska M, Wiechula B, Zientara M, Radosz-Komoniewska H. Antibiotic susceptibility analysis of Enterococcus spp. isolated from urine. Przegl Lek 2004;61:473-6 http://www.ncbi.nlm.nih.gov/pubmed/15515808.
• Ergin ÖY, Bayram DE, Uzun B, Güngör S, Demirdal T. Enterococcus species isolated from urine cultures and their antibiotic resistance. ANKEM Derg 2013;27:173-8.
• Lipsky BA, Berendt AR, Cornia P.B., Pile J.C., Peters E.J.G., Armstrong D.G., et al. 2012; IDSA Guidelines, http://www.cid.oxfordjournals.org (Accessed on March 22).
• Gilbert ND, Moellering RC, Eliopoulos MG, Chambers FH, Saag SM. The Sanford Guide to Antimicrobial Therapy. 42nd ed. Antimicrobial Therapy Inc.: Vienna;2012:34-5.
• Şahin H, Arsu G, Köseli D, Büke Ç. Evaluation of primary health care physicians knowledge on rational antibiotic use. Mikrobiyol Bul 2008;42:343-8.