Antibiotic Susceptibility Pattern And Clinical Features Of Klebsiella Sepsis: An 8-Year Single- Center Experience At Tertiary In Neonatal Intensive Care Unit

Yıl 2017, Cilt: 14 Sayı: 3, 110 - 113, 01.07.2017

Nilay Hakan , Mustafa Aydın Ayşegül Zenciroğlu Gönül Tanır Nurullah Okumuş

Öz

Aim: We aimed to investigate predisposing factors of neonatal sepsis caused by klebsiella strains, clinical features of these cases and antibiotic susceptibility patterns.Materials and Methods: The cases with klebsiella sepsis in the neonatal intensive care unit between 2005 and 2012 were retrospectively analyzed. Demographic and clinical characteristics of the patients were recorded together with their microbiological results.Results: 32 girls 54.2% and 27 boys 45.8% were included in the study. Out of 59 neonates, 46 cases 78% were preterm. Mean gestational age was 33.2±4.3 weeks minimum-maximum: 24-42 weeks ; the birth weight was 1968±794 g minimum-maximum: 730-4000 g . Isolated pathogens from blood cultures were mainly K. pneumoniae n:48, 81% , K. oxytoca n:6, 10% , K. terrigena n:3, 5% and K. ornithinolytica n:2, 4% . The primary diagnoses of the patients were prematurity and respiratory distress syndrome n:17, 29% , severe congenital heart disease n:11, 18% , necrotizing enterocolitis n:8, 13% and major congenital anomaly n:6, 10% . In total, 53 patients 90 % went through more than 2 invasive procedures prior to the development of bacteremia. The mortality rate due to klebsiella infection was found to be 19%. The most effective antibiotics against klebsiella strains were meropenem 97% and ciprofloxacin 91% . Resistance rates were found to be 86% against piperacillin, 85% against ceftazidime, 91% against ceftriaxone and 95% against cephaperozone. 50% of klebsiella strains were resistant to gentamicin and approximately 30% was resistant to amikacin and trimethoprim-sulfamethoxazole.Conclusion: Klebsiella infections associated with health care are mainly caused by K. pneumoniae. Low birth weight, early gestational weeks, invasive interventions and underlying severe illnesses are predisposing newborns to klebsiella infections. Multidrug resistance seems a major problem. Mortality is related to the underlying primary disease.

Anahtar Kelimeler

Klebsiella, sepsis, newborn, treatment, multi-drug resistance, mortality

Klebsiella Sepsisinin Klinik Özellikleri ve Antibiyotik Duyarlılık Paterni: Üçüncü Düzey Bir Yenidoğan Yoğun Bakım Ünitesindeki 8 Yıllık Deneyimlerimiz

Öz

Amaç: Klebsiella suşlarına bağlı neonatal sepsisdeki predispozan faktörleri, bu olguların klinik özelliklerini ve elde edilen antibiyotik duyarlılık paternlerini araştırmayı amaçladık.Gereç ve Yöntem: 2005-2012 yılları arasında yenidoğan yoğun bakım ünitesinde yatırılarak izlenmiş olan ve kanıtlanmış klebsiella sepsisi tanısı alan olgular geriye dönük olarak incelendi. Hastaların demografik ve klinik özellikleri ile mikrobiyolojik sonuçları kaydedildi.Bulgular: Çalışmaya alınan 59 olgunun 32’si %54.2 kız, 27’si %45.8 erkekti. Olguların 46’sı %78 preterm doğmuştu. Ortalama gebelik yaşı 33.2±4.3 hafta minimum- maksimum: 24-42 hafta ; doğum ağırlığı 1968±794 gr minimum-maksimum: 730-4000 gr idi. Kan kültürlerinden izole edilen etkenlerin başlıca K. pneumoniae n:48, %81 , K. oxytoca n:6, %10 , K. terrigena n:3, %5 ve K. ornithinolytica n:2, %4 olduğu belirlendi. Hastaların primer tanıları preterm ve respiratuar distres sendromu n:17, %29 , ciddi konjenital kalp hastalığı n:11, %18 , nekrotizan enterokolit n:8, %13 ve major konjenital anomali n:6, %10 idi. Bakteriyemi gelişmeden önce olguların 53’üne %90 ikiden fazla invaziv girişim uygulanmıştı. Klebsiella enfeksiyona bağlı mortalite oranının %19 olduğu saptandı. Klebsiella suşlarına karşı en etkili antibiyotikler meropenem %97 ve siprofloksasin %91 idi. Direnç oranlarının piperasiline karşı %86, seftazidime karşı %85, seftriaksona karşı %91, sefaperozona karşı ise %95 olduğu belirlendi. Klebsiella suşlarının %50’si gentamisine dirençli, yaklaşık %30’u ise amikasin ve trimetoprim-sulfametoksazole dirençliydi.Sonuç: Sağlık hizmeti ile ilişkili klebsiella enfeksiyonlarına başlıca K. pneumoniae neden olmaktadır. Düşük doğum ağırlığı, erken gebelik haftalarında doğum, invaziv girişimler ve altta yatan ciddi hastalıklar yenidoğanda klebsiella enfeksiyonlarına yatkınlık oluşturmaktadır. Günümüzde çoklu ilaç direnci önemli bir sorun olmaktadır. Mortalite sepsis ile beraber altta yatan primer hastalık ile ilişkilidir.

Anahtar Kelimeler

Klebsiella, sepsis, yenidoğan, tedavi, çoklu ilaç direnci, mortalite

Kaynakça

• Turkish Neonatal Society; Nosocomial Infections Study Group. Nosoco- mial infections in neonatal units in Turkey: epidemiology, problems, unit policies and opinions of healthcare workers. Turk J Pediatr 2010; 52:50- 7.
• Yalaz M, Arslanoğlu S, Çetin H, Aydemir Ş, Tünger A, Akısu M ve ark.. Üçüncü basamak yenidoğan yoğun bakım merkezinde kanıtlanmış no- zokomiyal sepsis etkenlerinin değerlendirilmesi: iki yıllık analiz. ADÜ Tıp Fakültesi Dergisi 2004; 5:5-9.
• García C, Astocondor L, Rojo-Bezares B, Jacobs J, Sáenz Y. Molecular characterization of extended-spectrum β-lactamase-producer Klebsiella pneumoniae isolates causing neonatal sepsis in Peru. Am J Trop Med Hyg 2016; 94:285-8.
• Patterson JE, Hardin TC, Kelly CA, Garcia RC, Jorgensen JH. Association of antibiotic utilization measures and control of multiple-drug resistance in Klebsiella pneumoniae. Infect Control Hosp Epidemiol 2000; 2:455- 458.
• Braykov NP, Eber MR, Klein EY, Morgan DJ, Laxminarayan R. Trends in resistance to carbapenems and third-generation cephalosporins among clinical isolates of Klebsiella pneumoniae in the United States, 1999- 2010. Infect Control Hosp Epidemiol 2013; 34:259-68.
• Ali Abdel Rahim KA, Ali Mohamed AM. Prevalence of Extended Spectrum β-lactamase-Producing Klebsiella pneumoniae in Clinical Isolates. Jun- dishapur J Microbiol 2014; 7: e17114.
• Peña C, Pujol M, Ardanuy C, Ricart A, Pallares R, Liñares J et al. Epi- demiology and successful control of a large outbreak due to Klebsiella pneumoniae producing extended-spectrum beta-lactamases. Antimicrob Agents Chemother 1998; 42:53-8.
• Preterm birth. World Health Organization. Available at: http://www.who. int/mediacentre/factsheets/fs363/en/ (Accessed June 2017)
• Töllner U. Early diagnosis of septicemia in the newborn. Clinical studies and sepsis score. Eur J Pediatr 1982; 138:331-7.
• Aydin M, Barut S, Akbulut HH, Ucar S, Orman A. Application of flow cy- tometry in the early diagnosis of neonatal sepsis. Ann Clin Lab Sci 2017; 47:184-190.
• Clinical and Laboratory Standards Institute (CLSI)/Performance Stan- dards for Antimicrobial Susceptibility Testing; Twenty-First, Informational Supplement, 2011; 31:M100-S21.
• Podschun R, Ullmann U. Klebsiella spp. as nosocomial pathogens: epi- demiology, taxonomy, typing methods, and pathogenicity factors. Clin Microbiol Rev 1998; 11:589-603.
• Petros AJ, O’Connell M, Roberts C, Wade P, van Saene HK. Systemic antibiotics fail to clear multidrug-resistant Klebsiella from a pediatric ICU. Chest 2001; 119:862-6.
• Livermore DM. Beta-Lactamases in laboratory and clinical resistance. Clin Microbiol Rev 1995; 8:557-84.
• Ayan M, Kuzucu C, Durmaz R, Aktas E, Cizmeci Z. Analysis of three outb- reaks due to Klebsiella species in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2003; 24: 495-500.
• Yigit H, Queenan AM, Anderson GJ, Domenech-Sanchez A, Biddle JW, Steward CD et al. Novel carbapenem-hydrolyzing beta-lactamase, KPC- 1, from a carbapenem-resistant strain of Klebsiella pneumoniae. Anti- microb Agents Chemother 2001; 45:1151-61.
• Hidron AI, Edwards JR, Patel J, Horan TC, Sievert DM, Pollock DA et al; NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data repor- ted to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol 2008; 29:996-1011.
• Strategy for the control of Antimicrobial Resistance in Ireland (SARI) Hospital Antimicrobial Stewardship Working Group, Health Protection Surveillance Centre (HSPC), Guidelines for antimicrobial stewardship in hospitals in Ireland (2009). Available at: https://www.hpsc.ie/A-Z/Mic- robiology Antimicrobial Resistance /InfectionControlandHAI/Guidelines/ (accessed May 2017)
• Petrosillo N, Giannella M, Lewis R, Viale P. Treatment of carbapenem-re- sistant Klebsiella pneumoniae: the state of the art. Expert Rev Anti Infect Ther 2013; 11:159-77.
• Çiftci İH, Karakeçe E, Aşık G, Demiray T, Er H. Karbapenem dirençli Kleb- siella pneumoniae suşlarında Oxa-48 ve KPC varlığının araştırılması. An- kem Derg 2013; 27:49-54.
• Akturk H, Sutcu M, Somer A, Aydın D, Cihan R, Ozdemir A et al. Car- bapenem-resistant Klebsiella pneumoniae colonization in pediatric and neonatal intensive care units: risk factors for progression to infection. Braz J Infect Dis 2016; 20:134-40.
• Gülay Z. Kinolonlarda dienç problem. ANKEM Derg 2002; 6:232-7.
• Borer A, Saidel-Odes L, Eskira S, Nativ R, Riesenberg K, Livshiz-Riven I et al. Risk factors for developing clinical infection with carbapenem-re- sistant Klebsiella pneumoniae in hospital patients initially only colonized with carbapenem-resistant K pneumoniae. Am J Infect Control 2012; 40:421-5.
• Silva J, Gatica R, Aguilar C, Becerra Z, Garza-Ramos U, Velázquez M et al. Outbreak of infection with extended-spectrum beta-lactamase-produ- cing Klebsiella pneumoniae in a Mexican hospital. J Clin Microbiol 2001; 39:3193-6.