Yoğun Bakım Hastalarında Hastane Kaynaklı Pnömoni Olgularının Değerlendirilmesi ve Sık Görülen Bakteriyel Etkenlerin Antimikrobiyallere Dirençlerinin Araştırılması

Öz

Amaç: Bu çalışmanın amacı; hastanemiz yoğun bakım üniteleri YBÜ ’nde yatmakta olan hastalardan alınan alt solunum yolu örneklerinden izole edilen hastane kaynaklı pnömoni HKP etkenlerinin tür dağılımlarını, direnç paternlerini ve etken-kolonizasyon oranlarını saptamaktır.Yöntem:Çalışmada 11.06.2012-01.01.2014 tarihleri arasında üreme saptanan 96 balgam ve 1023 endotrakeal aspirat ETA olmak üzere 1119 alt solunum yolu örneği retrospektif olarak incelenmiştir. ETA örnekleri kantitatif kültür, balgam örnekleri ise kalitatif kültür yöntemleri ile değerlendirilmiştir. Üreyen mikroorganizmaların ayrımı hastanemiz Enfeksiyon Kontrol Komitesi tarafından CDC kriterlerine göre yapılmıştır. İdentifikasyon ve antibiyotik duyarlılık testleri Vitek-2 bioMerieux, France otomatize sistemiyle çalışılmıştır.Bulgular: Toplam 678 hastadan alınan 1119 örnekten 1309 mikroorganizma izole edilmiştir. Bu mikroorganizmalardan 401 hastaya ait 962 mikroorganizma kolonizasyon, 277 hastaya ait 347 mikroorganizma ise etken olarak kabul edilmiştir. Etken mikroorganizmaların 338’i ETA, dokuzu balgam materyalinden üretilmiştir. En sık görülen etken microorganisms in ETA samples were 208 Acinetobacter baumannii 61.5% , 53 Pseudomonas spp. 15.6% , 20 Klebsiella pneumoniae 5.9% , 18 Staphylococcus aureus 5.3% , and 9 Escherichia coli 2.6% , those that are in sputum samples were 6 A. baumannii 66.6% , 2 Pseudomonas spp. 22.2% , 1, K. pneumoniae 11.1% . The microorganisms regarded as colonization were 272 A. baumannii 28.3% , 228 Enterobacteriaceae spp. 23.7% , 131 Pseudomonas spp. 13.6% , and 138 Candida spp. 14.3% . The most frequently isolated A. baumannii, Pseudomonas spp. and K. pneumoniae were found to be multiple antimicrobial resistance. Of patients with nosocomial pneumonia HAP , 235 were considered as ventilator-associated pneumonia VAP , but 63 were nonConclusion: HAP is a nosocomial infection with a high mortality rate, which is frequently seen in ICUs. Determining the microorganisms causing HAP in ICUs, and monitoring their antimicrobial susceptibilities is also important to reduce mortality and morbidity as well as to guide empirical therapy. The fact that most of the cases are late-onset displays that that duration of hospital stay is an important risk factor in terms of HAP. The most frequent causative agent was detected A. baumannii, and colistin for this microorganism was seen as the only treatment option. It should be kept in mind that colonized microorganisms may be causative infectious agents eventually, and the patients should be monitored

Anahtar Kelimeler

• hastane kökenli pnömoni, ventilatör ilişkili pnömoni, antimikrobiyal direnç, kolonizasyon

Analysis of Nosocomial Pneumonia and Antimicrobial Resistance of Frequently Encountered Bacterial Isolates in Intensive Care Unit Patients

Öz

Objective: The aim of the study is to investigate the distributions of species, resistance patterns and infectioncolonization rates of hospital acquired pneumoniae HAP agents which isolated from lower respiratory tracts of the patients hospitalized in intensive care units ICU .Method: In the study, it was retrospectively evaluated 1119 lower respiratory tract samples [96 sputum, 1023 endotracheal aspirates ETA ] with positive culture results, and obtained between June 11, 2012 January 01, 2014. Quantitative cultures were done in ETA samples, and qualitative cultures were done in sputum samples. Separation of growing microorganism on culture was done by Infection Control Committee of our hospital, in accordance with CDC criteria. Identification and antibiotic susceptibility tests were performed by Vitek-2 bioMerieux, France automated system. Results: One thousand three hundred and nine microorganisms were isolated from 1119 samples obtained from a total of 678 patients. Of those microorganisms, 962 isolates from 401 patients were considered as colonization, while 347 microorganisms isolated from 277 patients were accepted as causative agents. Of causative microorganisms, 338 were from ETA, nine were produced from sputum materials. The most frequently isolated microorganisms in ETA samples were 208 Acinetobacter baumannii 61.5% , 53 Pseudomonas spp. 15.6% , 20 Klebsiella pneumoniae 5.9% , 18 Staphylococcus aureus 5.3% , and 9 Escherichia coli 2.6% , those that are in sputum samples were 6 A. baumannii 66.6% , 2 Pseudomonas spp. 22.2% , 1, K. pneumoniae 11.1% . The microorganisms regarded as colonization were 272 A. baumannii 28.3% , 228 Enterobacteriaceae spp. 23.7% , 131 Pseudomonas spp. 13.6% , and 138 Candida spp. 14.3% . The most frequently isolated A. baumannii, Pseudomonas spp. and K. pneumoniae were found to be multiple antimicrobial resistance. Of patients with nosocomial pneumonia HAP , 235 were considered as ventilator-associated pneumonia VAP , but 63 were nonConclusion: HAP is a nosocomial infection with a high mortality rate, which is frequently seen in ICUs. Determining the microorganisms causing HAP in ICUs, and monitoring their antimicrobial susceptibilities is also important to reduce mortality and morbidity as well as to guide empirical therapy. The fact that most of the cases are late-onset displays that that duration of hospital stay is an important risk factor in terms of HAP. The most frequent causative agent was detected A. baumannii, and colistin for this microorganism was seen as the only treatment option. It should be kept in mind that colonized microorganisms may be causative infectious agents eventually, and the patients should be monitored

Anahtar Kelimeler

• hospital acquired pneumonia, ventilatorassociated pneumonia, antimicrobial resistance, colonization

Kaynakça

1. 1. Ding JG, Sun QF, Li KC, Zheng MH, Miao XH, Ni W, et al. Retrospective analysis of hospital acquired infections in the intensive care unit of a tertiary hospital in China during 2003 and 2007. BMC Infect Dis, 2009; 9: 115. http://dx.doi.org/10.1186/1471- 2334-9-115.
2. 2. Arman D. Yoğun bakım enfeksiyonlarının önemi ve epidemiyolojisi. Yoğun Bakım Derg, 2006; 6: 5-7.
3. 3. Yalçın A, Şen E, Erol S, Çiledağ A, Gülbay B, Önen ZP, ve ark. Solunum yoğun bakım ünitemizdeki enfeksiyon etkenleri ve direnç sorunu. Ortadoğu Tıp Derg, 2013; 5 (1): 17-24.
4. 4. Küme G, Demirci M. Yoğun bakım ünitelerindeki hastaların alt solunum yolu örneklerinden izole edilen non-fermantatif gram-negatif bakterilerin antimikrobiyal duyarlılıkları ve alt solunum yolu enfeksiyonu ile ilişkili risk faktörleri. DEÜ Tıp Fakültesi Derg, 2012;26(1):37-44.
5. 5. Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilatorassociated pneumonia: a systematic review. Critical care med, 2005; 33: 2184.
6. 6. Yılmaz N, Köse Ş, Ağuş N, Ece G, Akkoçlu G, Kıraklı C. Yoğun bakım ünitesinde yatan hastaların kan kültürlerinde üreyen mikroorganizmalar, antibiyotik duyaklılıkları ve nozokomiyal bakteriyemi etkenleri. ANKEM Derg, 2010; 24 (1): 12-9.
7. 7. Yalçın AN. Yoğun bakım ünitesinde antibiyotik kullanımı ve direnç sorununa genel bakış. ANKEM Derg, 2009; 23(Ek 2): 136-42.
8. 8. Ertürk A, Çiçek AÇ, Köksal E, Köksal ZŞ, Özyurt S. Yoğun bakım ünitesinde yatan hastaların çeşitli klinik örneklerinden izole edilen mikroorganizmalar ve antibiyotik duyarlılıkları. ANKEM Derg, 2012; 26 (1): 1-9. doi:10.5222/ankem.2012.001.

9. 9. De Champs C, Sauvant MP, Chanal C, Sirot D, Gazuy N, Malhuret R, et al. Prospective survey of colonization and infection caused by expandedspectrum-beta-lactamase-producing members of the family Enterobacteriaceae in an intensive care unit. J Clin Microbiol, 1989; 27: 2887–90.
10. 10. Lucet JC, Chevret S, Decre D, Vanjak D, Macrez A, Bedos JP, et al. Outbreak of multiply resistant Enterobacteriaceae in an intensive care unit: Epidemiology and risk factors for acquisition. Clin Infect Dis, 1996; 22: 430–6.
11. 11. Fadda G, Spanu T, Ardito F, Taddei C, Santangelo R, Siddu A, et al. Antimicrobial resistance among non-fermentative gram-negative bacilli isolated from the respiratory tracts of Italian inpatients: a 3-year surveillance study. Int J Antimicrob Agents, 2004; 23 (3): 254-61.
12. 12. Andriesse GI, Verhoef J. Hospital acquired pneumonia: rationalizing the approach to empirical therapy. Treat Respir Med, 2006; 5(1): 11-30.
13. 13. Gales AC, Sader H HS, Jones RN. Respiratory tract pathogens isolated from patients hospitalized with suspected pneumonia in Latin America: frequency of occurrence and antimicrobial susceptibility profile: results from the SENTRY Antimicrobial Surveillance Program (1997-2000). Diagn Microbiol Infect Dis, 2002; 44 (3): 301-11.
14. 14. Roby JJ, Marin de Lasela E, Poete P, Nicolas MH, Bodin L, Jarlier V, et al. Nosocomial bronchopneumonia in the critically ill. Histologic and bacteriologic aspect. Am Rev Respir Dis, 1992; 146 :1059-66.
15. 15. Elatrous S , Boukef R , Ouanes Besbes L, Marghli S, Nouira S, Abroug F, et al. Diagnosis of ventilatorassociated pneumonia: agreement between quantitative cultures of endotracheal aspiration and plugged telescoping catheter. Intensive Care Med, 2004; 30: 853-8.
16. 16. Gazi H, Ecemiş T, Kurutepe S, Gürsev N, Sürücüoğlu S. Hastanede yatan hastaların alt solunum yolu örneklerinden izole edilen gram-negatif bakterilerde antimikrobiyal direnç, KLİMİK Derg, 2011; 24 (2): 112- 5. doi:10.5152/kd.2011.27.
17. 17. Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, et al. The prevalence of hospital acquired infection in intensive care units in Europe. Results of the European prevalence of infection in intensive care (EPIC) study. EPIC International Advisory Committee. JAMA. 1995; 274 (8): 639-44.
18. 18. Legras A, Malvy D, Quinioux AI, Villers D, Bouachour G, Robert R, et al. Hospital acquired infections: prospective survey of incidence in five French intensive care units. Intensive Care Med, 1998; 24 (10): 1040-6.
19. 19. Spencer RC. Predominant pathogens found in the European prevalence of infection in intensive care study. Eur J Clin Microbiol Infect Dis, 1996; 15 (4): 281-5.
20. 20. Trilla A. Epidemiology of hospital acquired infections in adult intensive care units. Intensive Care Med, 1994; 20 (3): 1-4.
21. 21. Tüfek A, Tekin R, Dal T, Tokgöz O, Doğan E, Kavak GÖ, ve ark. Reanimasyon ünitesinde on yıllık sürede gelişen hastane enfeksiyonlarının değerlendirilmesi ve literatürün gözden geçirilmesi. Dicle Tıp Derg, 2012; 39 (4):492-8.
22. 22. Tomak Y, Ertürk A, Şen A, Erdivanlı B, Kurt A. Anestezi yoğun bakım ünitesinde ventilatör ilişkili pnömoni hızları ve etken mikroorganizmaların dağılımı. Şişli Eftal Hastanesi Tıp Bülteni, 2012; 46 (3): 115-9.
23. 23. Alp E, Güven M, Yıldız O, Aygen B, Voss A, Doğanay M . Incidence, risk factors and mortality of hospital acquired pneumonia in intensive care units: A prospective study. Ann Clin Microbiol Antimicrob, 2004; 3: 17. doi: 10.1186/1476-0711-3-17.
24. 24. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Hospital acquired infections in medical intensive care units in the United States. National Hospital acquired Infections Surveillance System. Crit Care Med, 1999; 27 (5): 887-92.
25. 25. Scheld WM, Mandell GL. Hospital acquired pneumonia: pathogenesis and recent advances in diagnosis and therapy. Rev Infect Dis, 1991; 13 (Suppl 9): 743- 51.
26. 26. Mayhall CG. Nosocomial pneumonia. Diagnosis and prevention. Infect Dis Clin North Am, 1997; 11 (2): 427- 57.
27. 27. Çetin ES, Aynalı A, Demirci S, Aşçı S, Arıdoğan BC. Nöroloji yoğun bakım ünitesinde yatan hastalardan izole edilen hastane infeksiyonu etkenleri. Ankara Üniv Tıp Fak Mecm, 2009; 62 (1): 13-7.
28. 28. Gonlugur U, Bakici MZ, Akkurt I, Efeoglu T. Antibiotic susceptibility patterns among respiratory isolates of gram-negative bacilli in a Turkish university hospital. BMC Microbiol, 2004; 4: 32.
29. 29. Goel N, Chaudhary U, Aggarwal R, Bala K. Antibiotic sensitivity pattern of gram negative bacilli isolated from the lower respiratory tract of ventilated patients in the Intensive care unit. Indian J Crit Care Med, 2009; 13(3): 148-51. doi: 10.4103/0972-5229.58540.
30. 30. Akın A, Esmaoğlu Çoruh A, Alp E, Canpolat DG. Anestezi yoğun bakım ünitesinde beş yıl içerisinde gelişen nozokomiyal enfeksiyonlar ve antibiyotik direncinin değerlendirilmesi. Erciyes Tıp Derg, 2011; 33 (1): 007-016.
31. 31. Çakır-Edis E, Çağlar T, Otkun M, Gürcan Ş, Hatipoğlu ON, Erkan T. Hastane kökenli pnömonilerde sorumlu etkenler ve antimikrobial direnç değişimi. İnfeksiyon Derg, 2006; 20 (2): 107-10.
32. 32. Alp E, Güven M, Yıldız O, Soylu S. Yoğun bakım ünitelerimizde nozokomiyal pnömoni insidansı, etkenleri ve antibiyotik direnci. Flora, 2004; 9 (2): 125-31.
33. 33. Erdem I, Ozgultekin A, Sengoz Inan A, Dincer E, Turan G, Ceran N, et al. Incidence, etiology, and antibiotic resistance patterns of gram-negative microorganisms isolated from patients with ventilator-associated pneumonia in a medical-surgical intensive care unit of a teaching hospital in istanbul, Turkey (2004-2006). Jpn J Infect Dis, 2008; 61 (5): 339-42.
34. 34. Göktaş U, Yaman G, Karahocagil MK, Bilici A, Katı İ, Berktaş M. Anestezi yoğun bakım ünitesinde hastane infeksiyonu etkenleri ve direnç profilinin değerlendirilmesi. Yoğun Bakım Derg, 2010; 8 (1): 13- 7.
35. 35. Jones RN, Sader HS, Beach ML. Contemporary in vitro spectrum of activity summary for antimicrobial agents tested against 18569 strains non-fermentative gram negative bacilli isolated in the SENTRY Antimicrobial Surveillance Program (1997-2001). Int J Antimicrob Agents, 2003; 22: 551-6.
36. 36. Günseren F, Mamıkoğlu L, Öztürk S, Yücesoy M, Biberoğlu K, Yuluğ N, et al. A surveillance study of antimicrobial resistance of gram negative bacteria isolated from intensive care units in eight hospitals in Turkey, J Antimicrob Chemother, 1999; 43 (3): 373-8. http://dx.doi.org/10.1093/jac/43.3.373 PMid:10223593.
37. 37. Chan-Tompkins NH. Multidrug-resistant gramnegative infections. Bringing back the old. Crit Care Nurs Q, 2011; 34 (2): 87-100. doi: 10.1097/ CNQ.0b013e31820f6e88.
38. 38. Kallen AJ, Hidron AI, Patel J, Srinivasan A. Multidrug resistance among gram-negative pathogens that caused healthcare-associated infections reported to the national healthcare safety network, 2006-2008. Infect Control Hosp Epidemiol, 2010; 31 (5): 528-31. doi: 10.1086/652152.
39. 39. Fujimura S, Nakano Y, Takane H, Kikuchi T, Watanabe A. Risk factors for health care-associated pneumonia: transmission of multidrug-resistant Pseudomonas aeruginosa isolates from general hospitals to nursing homes. Am J Infect Control, 2011; 39 (2): 173-5. doi: 10.1016/j.ajic.2010.06.020.