NEVŞEHİR İLİNDEKİ HEMODİYALİZ HASTALARINDA NAZAL METİSİLİN DİRENÇLİ STAPHYLOCOCCUS AUREUS VE KOAGÜLAZ NEGATİF STAFİLOKOK TAŞIYICILIĞININ ÇEŞİTLİ YÖNTEMLERLE ARAŞTIRILMASI

Öz

Hemodiyaliz hastalarında enfeksiyon, morbidite ve mortaliteyi etkileyen önemli faktörlerdendir. Diyalize giriş yolu, sık hospitalizasyon ve sağlık personeli ile temas enfeksiyon riskini artırmaktadır. Nazal Staphylococcus aureus ve diğer stafilokoklar, taşıyıcı hasta ve personel aracılığıyla vasküler giriş yolu enfeksiyonlarına neden olabilmektedirler. Bu çalışmada, hemodiyaliz hastalarında ve personelinde nazal S. aureus ve koagülaz negatif Staphylococcus (KNS) taşıyıcılığı tespit edilerek, izolatlarda metisilin direnci çeşitli yöntemlerle araştırılmıştır. Bu sayede, nozokomiyal enfeksiyon riskinin değerlendirilmesine katkıda bulunulması amaçlanmıştır. Çalışmaya Kasım 2019- Mart 2020 tarihleri arasında Nevşehir Devlet Hastanesi, H. Mustafa ve Türkan Öbekli Diyaliz Merkezi’nde tedavi alan 41'i kadın 52'si erkek 93 hemodiyaliz hastası ile 15 diyaliz personeli dahil edilmiştir. Aydınlatılmış onam formu imzalatıldıktan sonra nazal sürüntü örnekleri alınmıştır. Örneklerden izole edilen stafilokoklardaki metisilin direnci, Kirby-Bauer disk difüzyon yöntemi, PBP-2a lateks aglütinasyon (LA) testi ve gerçek zamanlı polimeraz zincir tepkimesi (RT-PCR) ile incelenmiştir. Hasta örneklerinin (n=93) 18’inde (%19.3) S. aureus, 11’inde (%11.8) KNS; personel örneklerinin (n=15) üçünde KNS (%20.0) ve birinde (%6.6) S. aureus izole edilmiştir. Disk difüzyon yöntemiyle hastalardan elde edilen S. aureus izolatlarından sadece birinin metisiline dirençli (%1), geri kalanının (%18.2) ve tüm KNS’lerin (%11.8) metisiline duyarlı olduğu saptanmıştır. Personel örneklerindeki KNS’lerin (%20.0) tümü metisiline duyarlı iken, izole edilen tek S. aureus dirençli bulunmuştur (%6.6). Tüm S. aureus izolatlarına (n=19), PBP-2a LA ve RT-PCR yapılmış; disk difüzyon ile metisilin dirençli S. aureus olarak tanımlanan iki izolatta da LA testi ve mecA geni pozitif bulunmuştur. Sonuç olarak, hemodiyaliz ünitelerindeki enfeksiyonların kontrolü için, portör taramalarının düzenli olarak yapılması gerekmektedir. İzole edilen mikroorganizmaların direnç profillerini saptayacak alternatif yöntemler, sağlık kuruluşunun ihtiyaçlarına ve donanımına göre tercih edilebilir.

Anahtar Kelimeler

• hemodiyaliz
• koagülaz negatif stafilokok
• mecA
• MRSA
• nazal taşıyıcılık
• PBP-2a

Investigation of Nasal Methicillin Resistant Staphylococcus aureus and Coagulase Negative Staphylococcus Carriage by Various Methods in Hemodialysis Patients in Nevşehir Province

Öz

Infection is one of the important factors affecting morbidity and mortality in hemodialysis patients. Access to dialysis, frequent hospitalizations, and contact with healthcare personnel increase the risk of infection. Nasal Staphylococcus aureus and other staphylococci may cause vascular access infections through carrier patients and staff. In this study, nasal S. aureus and coagulase-negative Staphylococcus (CNS) carriers were detected in hemodialysis patients and staff, and methicillin resistance in isolates was investigated by various methods. In this way, it was aimed to contribute to the assessment of nosocomial infection risk. Between November 2019 and March 2020, 93 hemodialysis patients, 41 female, 52 male, and 15 dialysis personnel treated at Nevşehir State Hospital, H. Mustafa and Türkan Öbekli Dialysis Center were included in the study. Nasal swab samples were obtained after the informed consent form was signed. Methicillin resistance in staphylococci isolated from the samples was determined by the Kirby-Bauer disk diffusion method, PBP-2a latex agglutination (LA) test, and real-time polymerase chain reaction (RT-PCR). Of the patient samples (n=93), 18 (19.3%) had S. aureus, 11 (11.8%) had CNS; of the personnel samples (n=15) CNS was isolated from three (20%) and S. aureus from one (6.6%). It was determined that one of the S. aureus isolated from the patients was methicillin-resistant (1%); the rest (18.2%) and all CNS (11.8%) were methicillin-susceptible by disk diffusion method. While all of the CNS (20%) in the personnel samples were susceptible to methicillin, only S. aureus was resistant (6.6%). The PBP-2a LA test and RT-PCR were performed on all S. aureus isolates (n=19); the PBP-2a LA test and mecA gene were positive in both isolates identified as methicillin-resistant S. aureus via disk diffusion. In conclusion, porter screenings should be done regularly to control infections in hemodialysis units. Alternative methods to determine the resistance profiles of isolated microorganisms might be preferred according to the needs and equipment of the health institution.

Anahtar Kelimeler

• coagulase negative staphylococci
• hemodialysis
• mecA
• MRSA
• nasal carriage
• PBP-2a

Kaynakça

1. Aydın, M, Yazıcı,S. Hastane personelindeki nazal Staphylococcus aureus tașıyıcılığının araștırılması. J Ankara Univ Fac Med. 2012;65(1):47-51.
2. Barbier F, Ruppé E, Hernandez D, et al. Methicillin-resistant coagulase-negative staphylococci in the community: high homology of SCCmec IVa between Staphylococcus epidermidis and major clones of methicillin-resistant Staphylococcus aureus. J Infect Dis. 2010;202(2):270-81.
3. Camargo CH, de Souza da Cunha MLR, Caramori JCT, Mondelli AL, Montelli AC, Barretti P. Incidence and characteristics of methicillin-resistant coagulase-negative Staphylococcus aureus in peritoneal dialysis-associated peritonitis in a single center using molecular methods. Int Urol Nephrol. 2021;53(2):373-80.
4. Cesur S,Kurşun Ö, AylıD, et al. Nasal Staphylococcus aureus carriage ratio of outpatients undergoing hemodialysis and mupirocin, fucidic acid, trimethoprim-sulfamethoxazole susceptibility of isolated strains. Ortadogu Tıp Derg. 2016;8(4):177-81.
5. Cuervo G, Camoez M, Shaw E, et al. Methicillin-resistant Staphylococcus aureus (MRSA) catheter-related bacteraemia in haemodialysis patients. BMC Infect Dis. 2015;15(484):1-7.
6. Elzorkany KMA, Elbrolosy AM, Salem EH. Methicillin-resistant Staphylococcus aureus carriage in hemodialysis vicinity: Prevalence and decolonization approach. Indian J Nephrol. 2019;29(4):282-87.
7. Emre A, Seyman D, Merve Türker M, et al. Cases with skin and soft tissue infections caused by community-acquired methicillin-resistant Staphylococcus aureus. Klimik Derg. 2020;33(2):180-4.
8. Gagnaire J, Botelho-Nevers E, Martin-Simoes P, et al. Interplay of nasal and rectal carriage of Staphylococcus aureus in intensive care unit patients. Eur J Clin Microbiol Infect Dis. 2019;38(10):1811-19.

9. Galia L, Ligozzi M, Bertoncelli A, Mazzariol A. Real-time PCR assay for detection of Staphylococcus aureus, Panton-Valentine Leucocidin and methicillin resistance directly from clinical samples. AIMS Microbiol. 2019;5(2):138-46.
10. Giarola LB, Dos Santos RR, Tognim MC, Borelli SD, Bedendo J. Carriage frequency, phenotypic and genotypic characteristics of Staphylococcus aureus isolated from dialysis and kidney transplant patients at a hospital in northern paraná. Braz J Microbiol. 2012;43(3):923-30.
11. Heraud S, Freydiere AM, Doleans-Jordheim A, Bes M, Tristan A, Vandenesch F, Laurent F, Dauwalder O. Direct identification of Staphylococcus aureus and determination of methicillin susceptibility from positive blood-culture bottles in a Bact/ALERT System using Binax Now S. aureus and PBP2a tests. Ann Lab Med. 2015;35(4):454-7.
12. Kallen AJ, Arduino MJ, Patel PR. Preventing infections in patients undergoing hemodialysis. Expert Rev Anti Infect Ther. 2010;8(6):643-55.
13. Kurutepe S, Ecemiş T, Sürücüoğlu S, Kürşat S, Özbakkaloğlu B. Hemodiyaliz hastalarında Staphylococcus aureus burun taşıyıcılığı ve suşların antibiyotik direnci. ANKEM Derg. 2005;19(2):88-91.
14. Lu PL, Tsai JC, Chiu YW, et al. Methicillin-resistant Staphylococcus aureus carriage, infection and transmission in dialysis patients, healthcare workers and their family members. Nephrol Dial Transplant. 2008;23(5):1659-65.
15. Miller SA, Karichu J, Kohner P, et al. Multicenter evaluation of a modified cefoxitin disk diffusion method and PBP2a testing to predict mecA-mediated oxacillin resistance in atypical Staphylococcus aureus. J Clin Microbiol. 2017;55(2):485-94.
16. Özel G, Aslan V, Erdem GB, Çağatay M, Şencan İ, Mert A. Stafilokoklarda metisilin duyarlılığının belirlenmesinde oksasilin, sefoksitin, seftizoksim ve moksalaktam disk difüzyon yöntemlerinin karşılaştırılması. Mikrobiyol Bul. 2011;45(2):258-65.
17. Rteil A, Kazma JM, El Sawda J, Gharamti A, Koubar SH, Kanafani ZA. Clinical characteristics, risk factors and microbiology of infections in patients receiving chronic hemodialysis. J Infect Public Health. 2020;13(8):1166-71.
18. Suzuki M, Satoh N, Nakamura M, Horita S, Seki G, Moriya K. Bacteremia in hemodialysis patients. World J Nephrol. 2016;5(6):489-96.
19. Tashakori M, Mohseni Moghadam F, Ziasheikholeslami N, et al. Staphylococcus aureus nasal carriage and patterns of antibiotic resistance in bacterial isolates from patients and staff in a dialysis center of southeast Iran. Iran J Microbiol. 2014;6(2):79-83.
20. Ünver S,Atasoyu EM, Evrenkaya TR,ve ark. Kateterle ilişkili bakteriyemide vücut florasının önemi. İnfeksiyon Derg. 2005;19(1):87-90.
21. Velasco D, del Mar Tomas M, Cartelle M, et al. Evaluation of different methods for detecting methicillin (oxacillin) resistance in Staphylococcus aureus. J Antimicrob Chemother. 2005;55(3):379-82.
22. Vural A, Afşar İ, Kurultay N, Demirci M. Staphylococcus aureus’da metı̇sı̇lı̇n dı̇rencı̇nı̇n saptanmasında dı̇sk dı̇füzyon, oksası̇lı̇n agar tarama, mı̇krodı̇lüsyon ve PBP2a lateks aglütı̇nasyon testlerı̇nı̇n karşılaştırılması. ANKEM Derg. 2011;25(3):145-49.
23. Wertheim HF, Melles DC, Vos MC, et al. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis. 2005;5(12):751-62.
24. Wu TH, Lee CY, Yang HJ, et al. Prevalence and molecular characteristics of methicillin-resistant Staphylococcus aureus among nasal carriage strains isolated from emergency department patients and healthcare workers in central Taiwan. J Microbiol Immunol Infect. 2019;52(2):248-54.
25. Yiğit N, Aktaş AE, Doğruman-Al F, Ayyıldız A. Identification of coagulase negative staphylococci isolated from blood cultures and determination of their methicillin resistance. Turk Hij Den Biyol Derg. 2008;65(2):61-6.
26. Zhang H, Li L, Jia H, Liu Y, Wen J, Wu A, Lu Q, Hou T, Yang Y, Yang H, Li W, Zong Z. Surveillance of Dialysis Events: one-year experience at 33 outpatient hemodialysis centers in China. Sci Rep. 2017;21;7(1):249. 30.