Extended-spectrum β Lactamase (ESBL) 음성과 양성인 Klebsiella pneumoniae 혈류 감염증 환자의 임상적 특성 및 예후 비교

곽희원 외 중앙대학교 의과대학 의과학연구소 2009 中央醫大誌 Vol.34 No.1/2

ESBL-producing Klebsiella pneumoniae are resistant to many antibiotics, and bloodstream infections by ESBL-producing Klebsiella pneumoniae are known to increase the treatment failure and the mortality rate, but further Korean studies are required. We conducted this study to test the hypothesis that the clinical outcomes and prognosis amomg patients with bloodstream infection by ESBL-non-producing Klebsiella pneumoniae and by ESBL-producing Klebsiella pneumoniae are different. One hundred forty two patients with a bloodstream infection by Klebsiella pneumoniae were enrolled in this study from January, 2003 to May, 2007 at Chung-Ang University Hospital. Demographic characteristics, the mortality rate, hospitalization, site of infection, underlying disease and source of infection were assessed and compared between patients with bloodstream infection by ESBL-non-producing Klebsiella pneumoniae and by ESBL-producing Klebsiella pneumoniae by a retrospective analysis. Age, sex, site of infection, underlying disease showed no significant difference between patients with bloodstream infection by ESBL-non-producing Klebsiella pneumoniae and by ESBL-producing Klebsiella pneumoniae. But the infections by ESBL-producing organism more developed among patients with longer hospitalization and longer recovery period than the infections by ESBL-non-producing organism, but the motality rate showed no significant difference. The infections by ESBL-nonroducing organism were mostly community acquired, whereas the infections by ESBL-producing organismswere mostly hospital acquired. In intensive care units, the infections by ESBL-producing organism needed significantly longer Intensive Care Unit hospitalization, but the motality rate showed no significant difference.

최근 2년간 충북대학교병원에서 분리된 ESBL 생성균주의 분리 및 항균제 감수성 양상

신경섭,이기형,신형식,이상진,손보라 충북대학교 의학연구소 2002 忠北醫大學術誌 Vol.12 No.2

연구목적: ESBL 생성균주는 이들 감염의 치료 실패와 원내감염을 야기할 수 있어 이들 균주를 신속하고 정확하게 검출하는 것은 매우 중요하다. 또한 임상 검체에서 이들 균주들이 분리되는 양상을 주기적으로 분석하고 항균제 감수성의 변화 양상을 파악하는 것은 이들 균에 의한 감염의 치료 및 조절을 위해 필요하다. 저자들은 충북대학병원에서 2년 동안 ESBL의 분리율, 검체 그리고 병동에서의 분포 및 항균제 감수성 양상을 조사하여 보고하는 바이다. 대상 및 방법: 2001년 4월부터 2002년 10월까지 충북대학병원 미생물 검사실에 배양이 의뢰된 검체를 대상으로 하였으며, ESBL의 분리율, 분리된 ESBL의 검체 및 병동별 분포 그리고 항균제 감수성 검사를 조사하였다. 결과: 2년 동안 ESBL의 분리율은 2001년과 2002년 E. coli에서 각각 2.2/5.8% 이었고 K. pneumoniae에서 각각 26.3/28.3% 이었다. 혈액에서 분리된 K. pneumoniae/E. coli에서 2001년 및 2002년 ESBL의 분리율은 각각 18.6%/5.3% 와 16.7%/0% 이었다. 분리된 ESBL의 검체 별 분포는 소변, 객담, 혈액 순이었다. 병동별 분리율 및 분포율은 외래환자 보다 입원환자에서 높았다. ESBL 생성 균주는 aminoglycoside 항균제 내성율이 비생성 균주 보다 입원환자에서 높았다. 광범위(extended spectrum) cephalosporins의 감수성 결과로 예측할 수 있는 ESBL의 예측율은 ceftazidime 항균제를 포함하였을 때 높았으며, cefoftaxime, ceftriaxone 및 ceftazidime 항균제를 모두 포함하였을 경우 85.7%의 예측율을 보였다. 결론: ESBL의 분리, 분포 및 항균제 감수성 양상은 ESBL의 경험적 치료 및 감염 전파의 조절에 도움을 줄 수 있으므로 지속적으로 감시해야 하며, 광범위 cephalosporin에 모두 양성인 ESBL이 존재하므로 검사실에서는 모든 균주에 대해서 ESBL 생성 유무를 검사하여 보고하여야 할 것이다. Purpose: Because extended-spectrumβ-lactamase (ESBL) producing strains can cause frequently therapeutic failure and infectious outbreak in hospitals, rapid and accurate detection of these strains are important. It is indispensible for treatment and control of its infection to know the trend of isolation and change of antimicrobial susceptability of ESBL producer. So authors analyzed isolation rates, distribution rates and antimicrobial susceptability of ESBL. Materials and Methods: For isolates in Chungbuk National University Hospital from April, 2001 to October, 2002, the isolation and distribution rates by specimen and by ward and antimicrobial susceptability were analyzed. The expected detection rates were analyzed by susceptability results of variable combination of extended spectrum cephalosporins. Results: In 2001 and 2002 years, the isolation rates of ESBL were 2.2/5.8% in E. coli, 26.3%/28.3% in K. pneumoniae respectively. For blood, ESBL producing K. pneumoniae/E.coli were isolated to 18.6%/5.3%, 16.7%/0%. Isolated ESBL were distributed in order of urine, sputum and blood. The isolation and distribution rate from admission patients were higher than from OPD patients. Resistance rate for aminoglycoside in ESBL producing strains were significantly higher than non-ESBL producer. By only results of antimicrobial susceptability of extended spectrum cephalosporins, the expected dectection rates of ESBL were high at ceftazidime among each antibiotics, and highest at ceftazidime vs ceftriaxone combination. Conclusion: Because the trend of isolation rate, distribution rate and antimicrobial susceptability were helpful for treatment and control of infectious transmission of ESBL, clinical physician and laboratory should continuously inspect these occurrence and trend. All susceptable isolates for extended spectrum cephalosporin should be detect and report because these isolates may be extended-spectrumβ-lactamase producer.

전국 12개 병원 환자에서 분리된 Extended-Spectrum β-Lactamase 생성 Escherichia coli와 Klebsiella pneumoniae

송원근,이경원,김선주,정석훈,장철훈,신혜정,조성란,안지영,어영,신종희,이혜수,홍성근,용동은,정윤섭 대한화학요법학회 2000 대한화학요법학회지 Vol.18 No.4

목적 : Extended-spectrum β-lactamase(ESBL) 생성 그람음성간균에 관한 연구가 우리나라에서도 있으나 전국 규모의 연구가 없었으므로 ESBL 생성 Escherichia coli와 Klebsiella pneumoniae의 비율을 검체별, 환자별로 규명하고 다른 항균제에 대한 감수성 양상을 조사하고자 하였다. 방법 : 1999년 9월부터 12월 사이에 전국 12개 병원의 임상검체에서 분리된 일련의 E. coli 1,171주와 K. pneumoniae 585주를 대상으로 하였다. ESBL 생성균주의 선별은 cefpodoxime, cefotaxime, ceftazidime, 및 aztreonam 디스크로 시험하여 National Committee for Clinical Laboratory Standards의 기준에 따라 해석하였고, double disk synergy 시험 양성인 경우를 ESBL 생성균주로 판정하였다. 결과 : 참여 병원 모두에서 ESBL 생성균주가 확인되었다. 균종별 ESBL 생성균주의 비율은 E. coli가 9.8% (3.5-19.6%)이었고, K. pneumoniae가 25.6% (10-41.3%)이었다. 검체 별로는 객담에서, 환자별로는 중환자실에서 분리된 ESBL 생성균주의 빈도가 각각 27.4%와 31.7%로 가장 높았다. ESBL 생성균주의 aminoglycoside제와 co-trimoxazole에 대한 내성율은 ESBL 비생성균주보다 현저히 높았다. 결론 : ESBL 생성 E. coli와 K. pneumoniae는 국내 병원에 널리 퍼져 있었으며, 요와 객담 검체에서 흔히 분리되었고, 중환자실 환자에서의 분리율이 높았고, 다른 항균제에 대한 내성율이 ESBL 비생성균주에 비해 높았다. Background : Presence of extended spectrum β-lactamase (ESBL) -producing gram-negative bacilli have been reported in Korea, but our understanding of the prevalence is limited. The aim of this study was to determine the nationwide prevalence and antimicrobial susceptibility of ESBL -producing Escherichia coli and Klebsiella pneumoniae, and to characterize the patients and sources. Methods: A total of 1.171 E. coli and 585 K. pneumoniae non-duplicate isolates were collected from 12 hospitals in September to December 1999. ESBL production was determined by National Committee for Clinical Laboratory Standards methods using cefpodoxime, cefotaxime, ceftazidime, and aztreonam disk. Positive double disk synergy tests were considered ESBL producers. Results : ESBL-producing E. coli and K. pneumoniae isolates were detected from all 12 hospitals. The proportion of ESBL-producers was 9.8% (3.5-19.6%) of the E. coli and 25.6% (10-41.3%) of the K.. pneumoniae isolates. The common source of ESBL-producers was sputum (27.4%) and patients in intensive care unit (31.7%). ESBL-producing isolates were more often resistant to aminoglycosides and cotrimoxazole. Conclusion : ESBL-producing E. coliand K.. pneumoniae are widespread to all levels of Korean hospitals. ESBL-producers are more prevalent among isolates from urine and sputum and from intensive care unit patients. These organisms are more often resistant than the non- ESBL -producers to amjnoglycosides and cotrimoxazole.

Cefpodoxime 디스크를 이용한 Extended-Spectrum β-Lactamase 생성 Klebsiella pneumoniae와 Escbericbia coli 선별법

송원근,김현태,이규만 대한임상병리학회 1999 대한임상병리학회지 Vol.19 No.2

Escherichia coli와 Klebsiella Species에서 Extended-Spectrum β-Lactamase 검출을 위한 Vitek ESBL Test와 그 외 방법의 비교

신경섭,손보라 대한임상병리학회 2002 대한임상병리학회지 Vol.22 No.1

Rates of Fecal Transmission of Extended-Spectrum β-Lactamase-Producing and Carbapenem-Resistant Enterobacteriaceae Among Patients in Intensive Care Units in Korea

김자영,이지영,김상일,송원근,김재석,정승원,유진경,박강균,박연준 대한진단검사의학회 2014 Annals of Laboratory Medicine Vol.34 No.1

Background: We investigated the rates of fecal transmission of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (ESBL-E) and carbapenem-resistant Enterobacteriaceae (CRE) among patients admitted to intensive care units (ICUs). Methods: From June to August 2012, rectal cultures were acquired from all patients at ICU admission. For patients not carrying ESBL-E or CRE at admission, follow-up cultures were performed to detect acquisition. A chromogenic assay was used to screen for ESBL-E and CRE. Bacterial species identification and antibiotic susceptibility testsㅌ were performed using the Vitek 2 system (bioMérieux, France). ESBL genotypes were determined by PCR, and clonal relatedness of the isolates was assessed by pulsed-field gel electrophoresis. Results: Out of 347 ICU admissions, 98 patients were found to be carriers of ESBL-E (28.2%, 98/347). Follow-up cultures were acquired from 91 of the patients who tested negative for ESBL-E at admission; the acquisition rate in this group was 12.1% (11/91), although none was a nosocomial transmission. For CRE, the prevalence of fecal carriage was 0.3% (1/347), and the acquisition rate was 2.9% (4/140). None of the CRE isolates were carbapenemase-producers. Conclusions: The high prevalence of ESBL-E carriage on admission (28.2%), coupled with rare nosocomial transmission and the very low carriage rate of CRE (0.3%), challenge the routine use of active surveillance in non-epidemic settings. Nevertheless, passive sur- veillance measures, such as rapid and accurate screening of clinical specimens, will be critical for controlling the spread of CRE. Background: We investigated the rates of fecal transmission of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (ESBL-E) and carbapenem-resistant Enterobacteriaceae (CRE) among patients admitted to intensive care units (ICUs). Methods: From June to August 2012, rectal cultures were acquired from all patients at ICU admission. For patients not carrying ESBL-E or CRE at admission, follow-up cultures were performed to detect acquisition. A chromogenic assay was used to screen for ESBL-E and CRE. Bacterial species identification and antibiotic susceptibility tests were performed using the Vitek 2 system (bioMérieux, France). ESBL genotypes were determined by PCR, and clonal relatedness of the isolates was assessed by pulsed-field gel electrophoresis. Results: Out of 347 ICU admissions, 98 patients were found to be carriers of ESBL-E (28.2%, 98/347). Follow-up cultures were acquired from 91 of the patients who tested negative for ESBL-E at admission; the acquisition rate in this group was 12.1% (11/91), although none was a nosocomial transmission. For CRE, the prevalence of fecal carriage was 0.3% (1/347), and the acquisition rate was 2.9% (4/140). None of the CRE isolates were carbapenemase-producers. Conclusions: The high prevalence of ESBL-E carriage on admission (28.2%), coupled with rare nosocomial transmission and the very low carriage rate of CRE (0.3%), challenge the routine use of active surveillance in non-epidemic settings. Nevertheless, passive sur- veillance measures, such as rapid and accurate screening of clinical specimens, will be critical for controlling the spread of CRE.

Prevalence of the Extended-Spectrum β-Lactamase and qnr Genes in Clinical Isolates of Escherichia coli

박용정,김재석,어영,정석훈,이경원,강현경,배일권,김주원 대한진단검사의학회 2009 Annals of Laboratory Medicine Vol.29 No.3

Background : This study was performed to investigate the prevalence of qnr genes in clinical isolates of Escherichia coli from Korea that produce extended-spectrum β-lactamases (ESBLs). Methods : During the period of May to June 2005, we collected clinical isolates of E. coli that were intermediate or resistant to ceftazidime and/or cefotaxime from 11 Korean hospitals. Antimicrobial susceptibility was determined by the disk diffusion and agar dilution methods. ESBL production was confirmed phenotypically by the double-disk synergy test. ESBL and qnr genes were searched for by PCR amplification, and the PCR products were then subjected to direct sequencing. Results : Double-disk synergy tests were positive in 84.3% (118/140) of ceftazidime- and/or cefotaxime-nonsusceptible E. coli isolates. The most prevalent types of ESBL in E. coli isolates were CTXM-14 (N=41) and CTX-M-15 (N=58). Other ESBLs were also identified, including CTX-M-3 (N=7), CTX-M-9 (N=8), CTX-M-12 (N=1), CTX-M-57 (N=1), SHV-2a (N=2), SHV-12 (N=17) and TEM-52 (N=4). The qnrA1 and qnrB4 genes were identified in 4 and 7 ESBL-producing isolates, respectively. Conclusions : CTX-M-type enzymes were the most common type of ESBL in E. coli isolates from Korea, and the qnr genes were not uncommon in ESBL-producing E. coli isolates. Dissemination of E. coli containing both ESBL and qnr genes could compromise the future usefulness of the expanded- spectrum antibiotics for the treatment of infections. Background : This study was performed to investigate the prevalence of qnr genes in clinical isolates of Escherichia coli from Korea that produce extended-spectrum β-lactamases (ESBLs). Methods : During the period of May to June 2005, we collected clinical isolates of E. coli that were intermediate or resistant to ceftazidime and/or cefotaxime from 11 Korean hospitals. Antimicrobial susceptibility was determined by the disk diffusion and agar dilution methods. ESBL production was confirmed phenotypically by the double-disk synergy test. ESBL and qnr genes were searched for by PCR amplification, and the PCR products were then subjected to direct sequencing. Results : Double-disk synergy tests were positive in 84.3% (118/140) of ceftazidime- and/or cefotaxime-nonsusceptible E. coli isolates. The most prevalent types of ESBL in E. coli isolates were CTXM-14 (N=41) and CTX-M-15 (N=58). Other ESBLs were also identified, including CTX-M-3 (N=7), CTX-M-9 (N=8), CTX-M-12 (N=1), CTX-M-57 (N=1), SHV-2a (N=2), SHV-12 (N=17) and TEM-52 (N=4). The qnrA1 and qnrB4 genes were identified in 4 and 7 ESBL-producing isolates, respectively. Conclusions : CTX-M-type enzymes were the most common type of ESBL in E. coli isolates from Korea, and the qnr genes were not uncommon in ESBL-producing E. coli isolates. Dissemination of E. coli containing both ESBL and qnr genes could compromise the future usefulness of the expanded- spectrum antibiotics for the treatment of infections.

Klebsiella pneumoniae의 Extended-spectrum β-lactamase 검출

이수연,이선화,배직현 대한임상병리학회 1997 대한임상병리학회지 Vol.17 No.6

임상검체에서 분리된 extended-spectrum β-lactam 항균제 분해 Klebsiella pneumoniae와 Escherichia coli의 성상

이경원,정윤섭,오까모도 료이찌,이노우에 마쓰히사 대한감염학회 1997 감염 Vol.29 No.6

목적:근래 분리되는 Escherichia coli와 Klebsiella pneumoniae 중에는 extended spectrum β-lactamase (ESBL)를 생산하는 균주가 많아졌다. NCCLS 디스크 확산법으로 ESBL 생산 균주를 정확히 거물하기 어렵다. 우리나라에서 분리되는 ESBL 생산 균주 중에는 디스크법으로 ceftazidime에 대해서 보다 cefotaxime에 내성이거나 중간 감수성인 것이 더 많다. 이 연구에서는 임상검체에서 분리되는 균주가 생산하는 ESBL의 성상을 밝히고자 하였다. 방법: 디스크 법으로 cefotaxime에 내성이나 중간 감수성인 E. coli와 K. pneumoniae 균주를 대상으로 double disk 법으로 ESBL 생산을 시험하고, 접합에 의한 내성전달 시험, 세균 파쇄 검체의 β-lactam제 가수분해 활성과 둥전점 시험, PCR에 의한 β-lactamase 유전자형 확인 시험을 하였다. 결과:시험된 E. coli 10주 중 9주와 K. pneumoniae 18주 모두는 double disk 시험 양성이었다. 접종균액이 10⁴CFU일 때는 cefotaxime의 MIC가 균주에 따라서 1.5-400㎍/mL 이었으나 10? CFU일때는 현저히 높아졌다. 선택된 일부 균주의 시험에서 내성 유전자가 접합에 의해서 전달되었으며, plasmid의 크기는 약 39 MDa이었다. 대부분의 transconjugant에 대한 cefotaxime의 MIC는 cefrazidime의 MIC 보다 높았다. 세균 파쇄 검체의 cefotaxime 가수분해 활성은 ceftazidime 가수분해 활성 보다 높았으며, TEM형의 pI는 5.9, SHV형은 7.8이었다. 결론:종합병원 환자에서 분리되는 E. coli와 K. pneumoniae 균주 중 디스크법으로 제 3세대 cephalosporin에 내성이나 중간인 균주는 대부분이 ESBL 생산 균주이고, 일부 균주에 대한 제 3세대 cephalosporin의 MIC는 접종균주가 10⁴일 때는 낮으므로 감수성 세균으로 오인될 수 있으며, cefotaxime 분해 활성이 ceftazidime 분해 활성 보다 더 높고, ESBL 생산균은 약 39 MDa의 plasmid를 가지고 있어서 제 3세대 cephalosporin 내성과 함께 gentamicin과 tobramycin 내성도 접합에 의해 전달된다는 결론을 얻었다. Background: Increase in Escherichial coli and Klebsiella pneumoniae isolates with extended-spectrum β-lactamase (ESBL) have been noted recently in Korea. Current NCCLS disk diffusion test is not sensitive to detect ESBL-producing strains. We have more isolates with intermediate or resistance to cefotaxime than to ceftazidime disk test. The aim of this study was to characterize the ESBLs produced by strains isolated from clinical specimens. Methods: E. coli and K. pneumoniae strains with cefotaxime intermediate or resistance by disk method were tested for ESBL production by double-disk synergy, transfer of resistance by conjugation, and relative hydrolysis of β-lactams and isoelectric point (pI) of cell sonicate. The types of β-lactamase gene were determined by PCR. Results:Nine of the 10 E. coli and all of the 18 K. pneumoniae strains tested were synergy test positive. The MIC of cefotaxime ranged from 1.5 to 400㎍/mL, with the inoculum of 10⁴CFU, but was much higher with larger inoculum. Some selected isolates showed that the resistance was transferable and the size of the plasmid was approximately 39 MDa. The MIC of cefotaxime was higher than that of ceftazidime in majority of the transconjugants. The hydrolytic activity of the sonicate was higher for cefotaxime than ceftazidime. TEM- and SHV-type genes were detected by PCR and the pI of the β-lactamase was 5.9 for 4 TEM-type and 7.8 for one SHV-type. Conclusion: Majority of te cefotaxime intermediate or resistant E. coli and K. pneumoniae isolated from the tertiary care hospital are TEM- or SHV-type ESBL producers. The inoculum size significantly affects the MIC value of β-lactams for the ESBL-producing strains. The ESBL hydorlyzes cefotaxime more actively than ceftazidime, and the ESBL gene is transferable by conjugation.

Antibiotic Resistance Mechanisms of Escherichia coli Isolates from Urinary Specimens

송성욱,이은영,고은미,하호성,정호중,배일권,정석훈 대한진단검사의학회 2009 Annals of Laboratory Medicine Vol.29 No.1

Background : This study was designed to characterize urinary isolates of Escherichia coli that produce extended-spectrum β-lactamases (ESBLs) and to determine the prevalence of other antimicrobial resistance genes. Methods : A total of 264 non-duplicate clinical isolates of E. coli were recovered from urine specimens in a tertiary-care hospital in Busan in 2005. Antimicrobial susceptibility was determined by disk diffusion and agar dilution methods, ESBL production was confirmed using the double-disk synergy (DDS) test, and antimicrobial resistance genes were detected by direct sequencing of PCR amplification products. E. coli isolates were classified into four phylogenetic biotypes according to the presence of chuA, yjaA, and TSPE4. Results : DDS testing detected ESBLs in 27 (10.2%) of the 264 isolates. The most common type of ESBL was CTX-M-15 (N=14), followed by CTX-M-3 (N=8) and CTX-M-14 (N=6). All of the ESBLproducing isolates were resistant to ciprofloxacin. PCR experiments detected genes encoding DHA- 1 and CMY-10 AmpC β-lactamases in one and two isolates, respectively. Also isolated were 5 isolates harboring 16S rRNA methylases, 2 isolates harboring Qnr, and 19 isolates harboring AAC(6’)- Ib-cr. Most ESBL-producing isolates clustered within phylogenetic groups B2 (N=14) and D (N=7). Conclusion : CTX-M enzymes were the dominant type of ESBLs in urinary isolates of E. coli, and ESBL-producing isolates frequently contained other antimicrobial resistance genes. More than half of the urinary E. coli isolates harboring CTX-M enzymes were within the phylogenetic group B2. Background : This study was designed to characterize urinary isolates of Escherichia coli that produce extended-spectrum β-lactamases (ESBLs) and to determine the prevalence of other antimicrobial resistance genes. Methods : A total of 264 non-duplicate clinical isolates of E. coli were recovered from urine specimens in a tertiary-care hospital in Busan in 2005. Antimicrobial susceptibility was determined by disk diffusion and agar dilution methods, ESBL production was confirmed using the double-disk synergy (DDS) test, and antimicrobial resistance genes were detected by direct sequencing of PCR amplification products. E. coli isolates were classified into four phylogenetic biotypes according to the presence of chuA, yjaA, and TSPE4. Results : DDS testing detected ESBLs in 27 (10.2%) of the 264 isolates. The most common type of ESBL was CTX-M-15 (N=14), followed by CTX-M-3 (N=8) and CTX-M-14 (N=6). All of the ESBLproducing isolates were resistant to ciprofloxacin. PCR experiments detected genes encoding DHA- 1 and CMY-10 AmpC β-lactamases in one and two isolates, respectively. Also isolated were 5 isolates harboring 16S rRNA methylases, 2 isolates harboring Qnr, and 19 isolates harboring AAC(6’)- Ib-cr. Most ESBL-producing isolates clustered within phylogenetic groups B2 (N=14) and D (N=7). Conclusion : CTX-M enzymes were the dominant type of ESBLs in urinary isolates of E. coli, and ESBL-producing isolates frequently contained other antimicrobial resistance genes. More than half of the urinary E. coli isolates harboring CTX-M enzymes were within the phylogenetic group B2.