{"id":22132,"date":"2021-04-28T14:49:12","date_gmt":"2021-04-28T11:49:12","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=22132"},"modified":"2021-06-02T21:22:01","modified_gmt":"2021-06-02T18:22:01","slug":"staphylococcus-aureus-izolatlarinin-cesitli-antibiyotiklere-duyarliliklarinin-degerlendirilmesi","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2021\/04\/28\/staphylococcus-aureus-izolatlarinin-cesitli-antibiyotiklere-duyarliliklarinin-degerlendirilmesi\/","title":{"rendered":"Staphylococcus aureus<\/i> \u0130zolatlar\u0131n\u0131n \u00c7e\u015fitli Antibiyotiklere Duyarl\u0131l\u0131klar\u0131n\u0131n De\u011ferlendirilmesi"},"content":{"rendered":"

\u00a0<\/strong>G\u0130R\u0130\u015e<\/strong><\/h2>\n

Staphylococcus aureus<\/em>, bakteriyemi, infektif endokardit, deri ve yumu\u015fak doku infeksiyonlar\u0131n\u0131n ve osteoartrik\u00fcler infeksiyonlar\u0131n ba\u015fl\u0131ca etkeni olup hem toplum kaynakl\u0131 hem de hastane kaynakl\u0131 infeksiyonlara yol a\u00e7abilmektedir (1). Bu bakteri modern antibiyotik \u00e7a\u011f\u0131n\u0131n ba\u015f\u0131ndan bu yana antistafilokokal ila\u00e7lar\u0131n t\u00fcm\u00fcne kar\u015f\u0131 ilerleyici bir diren\u00e7 geli\u015ftirme yetene\u011fi sergilemi\u015ftir (2,3). Stafilokoklar\u0131n metisilin ve di\u011fer penisilinaza diren\u00e7li penisilinlerin kullan\u0131m\u0131n\u0131 takiben bir\u00e7ok antimikrobiyale kar\u015f\u0131 zamanla \u00e7oklu ila\u00e7 direnci kazanmas\u0131, stafilokok infeksiyonlar\u0131n\u0131n tedavi se\u00e7eneklerini daraltmaktad\u0131r (4).<\/p>\n

Metisiline diren\u00e7li S. aureus <\/em>(MRSA) su\u015flar\u0131, t\u00fcm \u03b2-laktamlara diren\u00e7li olmas\u0131n\u0131n yan\u0131 s\u0131ra makrolidler, kinolonlar, tetrasiklinler, linkozamidler ve aminoglikozidlere de diren\u00e7 g\u00f6sterebilmektedir (5,6). MRSA\u2019n\u0131n etken oldu\u011fu invazif infeksiyonlar\u0131n tedavisinde glikopeptid grubu antibiyotiklerin, \u00f6zellikle vankomisinin s\u0131k kullan\u0131m\u0131 sonucunda; vankomisine orta d\u00fczeyde duyarl\u0131 (VISA), heterojen orta d\u00fczeyde duyarl\u0131 (hVISA) ve diren\u00e7li (VRSA) S. aureus <\/em>su\u015flar\u0131n\u0131n ortaya \u00e7\u0131kt\u0131\u011f\u0131 bildirilmektedir (7). Di\u011fer yandan, teikoplanin direncinin vankomisine g\u00f6re daha \u00e7abuk geli\u015fti\u011fi, disk dif\u00fczyon y\u00f6ntemiyle yeterince saptanamad\u0131\u011f\u0131 ve dolay\u0131s\u0131yla minimal inhibitor konsantrasyonu (M\u0130K) belirlemenin gereklili\u011fi de ortaya \u00e7\u0131km\u0131\u015ft\u0131r (8).<\/p>\n

Oksazolidinon grubunun \u00fcyesi olan linezolid, ribozomun 50S alt \u00fcnitesine ba\u011flanarak protein sentezinin ba\u015flamas\u0131n\u0131 inhibe etmekte ve Gram-pozitif bakterilerin etken oldu\u011fu infeksiyonlar\u0131n tedavisinde yayg\u0131n olarak kullan\u0131lmaktad\u0131r (9). Bu yayg\u0131n kullan\u0131mla birlikte linezolide kar\u015f\u0131 etkinlik azalmas\u0131 ve\/veya diren\u00e7 geli\u015fimi, buna ba\u011fl\u0131 olarak da tedavi ba\u015far\u0131s\u0131zl\u0131klar\u0131 bildirilmektedir (10).<\/p>\n

\u00c7al\u0131\u015fmam\u0131zda \u00f6zellikle MRSA infeksiyonlar\u0131nda ba\u015fl\u0131ca tedavi ajan\u0131 olan vankomisin, teikoplanin ve linezolidin minimal inhibit\u00f6r konsantrasyonu (M\u0130K) de\u011ferlerinin belirlenmesi, hastanemizin klinik \u00f6rneklerinden soyutlanan S. aureus <\/em>izolatlar\u0131n\u0131n antimikrobiyal ajanlara kar\u015f\u0131 in vitro<\/em> etkinliklerinin saptanarak hastanemizde S.aureus<\/em>\u2019un etken oldu\u011fu infeksiyonlarda uygulanacak tedavi yakla\u015f\u0131m\u0131na yard\u0131mc\u0131 olunmas\u0131 ama\u00e7lanm\u0131\u015ft\u0131r.<\/p>\n

\u00a0<\/strong>Y\u00d6NTEMLER<\/strong><\/h2>\n

Ocak 2016-Kas\u0131m 2019 tarihleri aras\u0131nda hastanemizin T\u0131bbi Mikrobiyoloji Laboratuvar\u0131nda, yatarak ve ayaktan tedavi edilen hastalar\u0131n \u00e7e\u015fitli klinik \u00f6rneklerinden izole edilen MRSA ve metisiline duyarl\u0131 S. aureus <\/em>(MSSA) sus\u0327lar\u0131 \u00e7al\u0131\u015fmaya dahil edilmi\u015ftir. \u00d6rnek say\u0131s\u0131 daha fazla olmas\u0131na ra\u011fmen, gradyan test y\u00f6ntemi 100 MRSA ve 100 MSSA sus\u0327u olmak \u00fczere toplam 200 hastada \u00e7al\u0131\u015f\u0131labilmi\u015f ve hastaya ait sadece bir su\u015f \u00e7al\u0131\u015fmaya dahil edilmi\u015ftir.<\/p>\n

Kan k\u00fclt\u00fcrleri BACTEC 9240 (Becton Dickinson Co., Diagnostic Instrument System, Sparks, MD, ABD) tam otomatik kan k\u00fclt\u00fcr\u00fc cihaz\u0131nda \u00e7al\u0131\u015f\u0131lm\u0131\u015ft\u0131r. Otomatize kan k\u00fclt\u00fcr\u00fc cihaz\u0131nda \u00fcreme saptanan \u015fi\u015felerden MacConkey agar, \u00e7ikolatams\u0131 agar ve %5 koyun kanl\u0131 agara pasaj yap\u0131lm\u0131\u015ft\u0131r. \u0130drar, derin trakeal aspirat, balgam, doku-apse, kateter ucu, steril s\u0131v\u0131lar\u0131n k\u00fclt\u00fcrleri materyaline g\u00f6re ve usul\u00fcne uygun olarak standart mikrobiyolojik teknikler kullan\u0131larak de\u011ferlendirilmi\u015ftir (11). Koyun kanl\u0131 agarda, S. aureus<\/em> oldu\u011fu d\u00fc\u015f\u00fcn\u00fclen \u03b2-hemoliz olu\u015fturan kolonilerden, katalaz- ve koag\u00fclaz-pozitif (Plasmatec, Rapid Latex Test, Birle\u015fik Krall\u0131k) olanlar i\u015fleme al\u0131nm\u0131\u015f ve otomatik identifikasyon sistemi (Phoenix\u2122 100, Becton Dickinson Co., Diagnostic Instrument System, Sparks, MD, ABD) ile kesin tan\u0131mlama yap\u0131lm\u0131\u015ft\u0131r. S. aureus <\/em>su\u015flar\u0131nda vankomisin, teikoplanin, linezolid duyarl\u0131l\u0131klar\u0131, \u00fcretici firman\u0131n \u00f6nerileri do\u011frultusunda gradyan test \u015feritleri (E-Test\u00ae bioM\u00e9rieux, Marcy l’Etoile, Fransa) kullan\u0131larak \u00e7al\u0131\u015f\u0131lm\u0131\u015ft\u0131r. Bu ama\u00e7la t\u00fcm su\u015flar\u0131n koyun kanl\u0131 agardaki pasajlar\u0131ndan 0.5 McFarland bulan\u0131kl\u0131\u011f\u0131nda bakteri s\u00fcspansiyonlar\u0131 haz\u0131rlanm\u0131\u015f ve Mueller-Hinton agara (Becton Dickinson Co., Sparks, MD, ABD) yay\u0131larak besiyeri \u00fczerine E-test\u00ae \u015feritleri yerle\u015ftirilmi\u015ftir. 35\u00b0C\u2019de 24 saat ink\u00fcbasyon sonras\u0131nda inhibisyon zonlar\u0131n\u0131n E-test\u00ae \u015feridini kesti\u011fi noktadaki M\u0130K de\u011ferleri kaydedilmi\u015f; elde edilen M\u0130K de\u011ferleri Avrupa Antimikrobiyal Duyarl\u0131l\u0131k Testi Komitesi (The European Committee on Antimicrobial Susceptibility Testing \u2013 EUCAST)<\/span>\u2019nin Staphylococcus <\/em>spp. i\u00e7in \u00f6nerdi\u011fi s\u0131n\u0131r de\u011ferler kullan\u0131larak yorumlanm\u0131\u015ft\u0131r (12). Buna g\u00f6re, S. aureus<\/em> i\u00e7in, vankomisin, teikoplanin ve linezolid M\u0130K de\u011ferleri s\u0131ras\u0131yla, \u22642 \u00b5g\/ml, \u22642 \u00b5g\/ml, \u22644 \u00b5g\/ml olanlar duyarl\u0131, \u22652 \u00b5g\/ml, \u22652 \u00b5g\/ml, \u22654 \u00b5g\/ml olanlar diren\u00e7li olarak kabul edilmi\u015ftir. Di\u011fer antibiyotiklerin duyarl\u0131l\u0131klar\u0131 otomatize sistemle yap\u0131lm\u0131\u015f ve EUCAST \u00f6nerilerine g\u00f6re de\u011ferlendirilmi\u015ftir. Kontrol su\u015fu olarak S. aureus<\/em> ATCC 29213 kullan\u0131lm\u0131\u015ft\u0131r.<\/p>\n

BULGULAR<\/strong><\/h2>\n
\"\"<\/a>

Tablo 1. <\/strong>MRSA ve MSSA Su\u015flar\u0131n\u0131n \u0130zole Edildikleri B\u00f6l\u00fcmlere G\u00f6re Da\u011f\u0131l\u0131m\u0131<\/p><\/div>\n

\"\"<\/a>

Tablo 2.<\/strong> MRSA ve MSSA Su\u015flar\u0131n \u0130zole Edildikleri \u00d6rneklere G\u00f6re Da\u011f\u0131l\u0131m\u0131<\/p><\/div>\n

\"\"<\/a>

Tablo 3.<\/strong> S. aureus <\/i>Su\u015flar\u0131 i\u00e7in Belirlenen M\u0130K De\u011ferleri (\u00b5g\/ml)<\/p><\/div>\n

\"\"<\/a>

Tablo 4.<\/strong>S. aureus<\/i> Su\u015flar\u0131n\u0131n Di\u011fer Antibiyotiklere Kar\u015f\u0131 Diren\u00e7 Durumlar\u0131<\/p><\/div>\n

\"\"<\/a>

\u015eekil 1.<\/strong> MRSA izolatlar\u0131nda M\u0130K da\u011f\u0131l\u0131mlar\u0131.<\/p><\/div>\n

\"\"<\/a>

\u015eekil 2.<\/strong> MSSA izolatlar\u0131nda M\u0130K da\u011f\u0131l\u0131mlar\u0131.<\/p><\/div>\n

\u00c7al\u0131\u015fmaya al\u0131nan MRSA su\u015flar\u0131n\u0131n %75\u2019i ve MSSA su\u015flar\u0131n\u0131n %66\u2019s\u0131 yatan hastalara ait \u00f6rneklerden izole edilmi\u015ftir. MRSA izolatlar\u0131n\u0131n %43\u2019\u00fc kad\u0131n, %57\u2019si erkek; MSSA izolatlar\u0131n\u0131n %46\u2019si kad\u0131n, %54\u2019\u00fc erkek hastalardan soyutlanm\u0131\u015ft\u0131r. Klinik \u00f6rneklerinden MRSA ve MSSA izole edilen kad\u0131n hastalar\u0131n ya\u015f ortalamas\u0131 s\u0131ras\u0131yla 42.78 ile 48.08; erkek hastalar\u0131n ya\u015f ortalamas\u0131 41.50 ile 45.13 olarak saptanm\u0131\u015ft\u0131r. \u00c7ocuk klini\u011fi (%16.5) d\u0131\u015f\u0131nda gelen \u00f6rnekler eri\u015fkin hastalara aittir (Tablo 1). \u0130zolatlar s\u0131kl\u0131kla yatan hastalardan izole edilmi\u015f olup MRSA su\u015flar\u0131n\u0131n %40\u2019\u0131, MSSA su\u015flar\u0131n\u0131n ise %21\u2019i yo\u011fun bak\u0131m k\u00f6kenlidir. MRSA ve MSSA su\u015flar\u0131n\u0131n izole edildikleri b\u00f6l\u00fcmlere g\u00f6re da\u011f\u0131l\u0131m\u0131 Tablo 1\u2019de g\u00f6sterilmi\u015ftir. K\u00f6kenlerin izole edildi\u011fi \u00f6rneklerin s\u0131kl\u0131kla doku-apse (%41.5) ve kan (%38) \u00f6rne\u011fi oldu\u011fu saptanm\u0131\u015ft\u0131r. MRSA ve MSSA su\u015flar\u0131n\u0131n izole edildikleri \u00f6rneklere g\u00f6re da\u011f\u0131l\u0131m\u0131 Tablo 2\u2019de verilmi\u015ftir.<\/p>\n

\u00c7al\u0131\u015fmam\u0131zda gradyan testle vankomisin, teikoplanin ve linezolid diren\u00e7li S. aureus <\/em>su\u015funa rastlanmam\u0131\u015ft\u0131r. Otomatize sistemle 7 MRSA izolat\u0131nda teikoplanin diren\u00e7li bulunmu\u015f, ancak gradyan testle duyarl\u0131 saptanm\u0131\u015ft\u0131r. Vankomisin, teikoplanin ve linezolid i\u00e7in M\u0130K50 <\/sub>ve M\u0130K90 <\/sub>de\u011ferleri Tablo 3\u2019te belirtilmi\u015ftir. MRSA ve MSSA izolatlar\u0131n\u0131n vankomisin, teikoplanin ve linezolid M\u0130K de\u011feri da\u011f\u0131l\u0131mlar\u0131 \u015eekil 1 ve \u015eekil 2\u2019de g\u00f6sterilmi\u015ftir. M\u0130K90 <\/sub>de\u011ferleri esas al\u0131nd\u0131\u011f\u0131nda MRSA su\u015flar\u0131nda linezolidin vankomisine g\u00f6re 1.3, teikoplanine g\u00f6re 2 kat daha etkin; MSSA su\u015flar\u0131nda ise linezolidin vankomisine ve teikoplanine g\u00f6re 1.5\u2019ar kat daha etkin oldu\u011fu bulunmu\u015ftur. Di\u011fer antibiyotiklerin etkinli\u011fine bak\u0131ld\u0131\u011f\u0131nda (Tablo 4); MRSA su\u015flar\u0131nda daptomisin, tigesiklin, kotrimoksazol ve k\u0131smen fusidik asid d\u0131\u015f\u0131ndaki t\u00fcm ajanlara kar\u015f\u0131 y\u00fcksek diren\u00e7 oranlar\u0131 saptanm\u0131\u015ft\u0131r. MSSA su\u015flar\u0131nda ise t\u00fcm antibiyotiklerin olduk\u00e7a etkin oldu\u011fu izlenmi\u015ftir.<\/p>\n

\u0130RDELEME<\/strong><\/h2>\n

G\u00fcn\u00fcm\u00fczde S. aureus<\/em>, t\u00fcm d\u00fcnyada ba\u015fl\u0131ca hastane kaynakl\u0131 patojenler aras\u0131nda yer almaktad\u0131r. \u00d6zellikle de MRSA su\u015flar\u0131, MSSA su\u015flar\u0131yla kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda daha uzun hastanede yat\u0131\u015f s\u00fcresi ve daha y\u00fcksek mortaliteyle seyreden infeksiyonlara yol a\u00e7malar\u0131 sebebiyle \u00f6nemli bir sorun olmaya devam etmektedir (1). \u00c7al\u0131\u015fmam\u0131za dahil edilen S. aureus <\/em>su\u015flar\u0131 s\u0131kl\u0131kla yatan hastalardan izole edilmi\u015f olup MRSA su\u015flar\u0131n\u0131n %40\u2019\u0131, MSSA su\u015flar\u0131n\u0131n %21\u2019i yo\u011fun bak\u0131m k\u00f6kenlidir. Uzun s\u00fcreli hastanede yat\u0131\u015f, ileri ya\u015f, altta yatan hastal\u0131klar, malignite, \u00f6nceden antibiyotik kullan\u0131m\u0131 ve en \u00f6nemlisi uygulanan invazif i\u015flemler bu bakterilerle geli\u015fen infeksiyonlarda ba\u015fl\u0131ca risk fakt\u00f6rleridir (2). Literat\u00fcr bilgileriyle uyumlu olarak \u00e7al\u0131\u015fmam\u0131zda S. aureus <\/em>izolasyonlar\u0131 yatan hastalarda, ayakta hastalara oranla y\u00fcksek oranda g\u00f6r\u00fclm\u00fc\u015f ve giri\u015fimsel i\u015flem yap\u0131lan servislerde yatan hastalarda daha s\u0131kl\u0131kla S. aureus<\/em> izole edilmi\u015ftir. \u00c7al\u0131\u015fmam\u0131zda \u00fclkemizdeki \u00e7al\u0131\u015fmalarla benzer \u015fekilde, hem MRSA hem de MSSA su\u015flar\u0131 en s\u0131kl\u0131kla yara (%41.5) ve kan (%8) kaynakl\u0131 \u00f6rneklerden olu\u015fmu\u015ftur (13-16).<\/p>\n

Metisiline direncin yayg\u0131nla\u015fmas\u0131yla birlikte MRSA\u2019ya ba\u011fl\u0131 invazif infeksiyonlu hastalar\u0131n tedavisinde vankomisin s\u0131kl\u0131kla kullan\u0131lmaya ba\u015flam\u0131\u015ft\u0131r. Buna ba\u011fl\u0131 olarak son y\u0131llarda d\u00fcnyan\u0131n de\u011fi\u015fik b\u00f6lgelerinden ve \u00fclkemizden diren\u00e7li izolatlar\u0131n varl\u0131\u011f\u0131 rapor edilmektedir (5,16,17). \u00c7al\u0131\u015fmam\u0131zda, MRSA ve MSSA izolatlar\u0131nda vankomisin direnci saptanmam\u0131\u015f olup M\u0130K50<\/sub>, M\u0130K90<\/sub> de\u011ferleri ve M\u0130K aral\u0131klar\u0131 s\u0131ras\u0131yla MRSA i\u00e7in 1.5\/2, 0.38-2 \u00b5g\/ml; MSSA i\u00e7in 1\/1.5, 0.38-2 \u00b5g\/ml \u015feklinde izlenmi\u015ftir. \u00c7elikbilek ve arkada\u015flar\u0131 (18)\u2019n\u0131n Ankara\u2019dan bildirdikleri \u00e7al\u0131\u015fmalar\u0131nda MRSA su\u015flar\u0131nda M\u0130K50<\/sub>, M\u0130K90<\/sub> de\u011ferlerini ve M\u0130K aral\u0131klar\u0131n\u0131 vankomisin i\u00e7in 1\/1.5 ve 0.25-3.00 \u00b5g\/ml; Ho\u015fbul ve arkada\u015flar\u0131 (4) s\u0131ras\u0131yla 1.5\/2, 0.5-3 \u00b5g\/ml \u015feklinde bildirmi\u015flerdir. Yeni\u015fehirli ve arkada\u015flar\u0131 (13) Tokat\u2019tan s\u0131ras\u0131yla 1.5\/1, 0.5-2 \u015feklinde; Bay\u0131nd\u0131r Bilman ve \u00c7i\u00e7ek (19) \u0130zmir\u2019den 0.25\/0.5, 0.125-1 \u015feklinde belirlemi\u015flerdir. \u00c7\u0131kman ve arkada\u015flar\u0131 (20) \u00e7ok merkezli \u00e7al\u0131\u015fmalar\u0131nda bu oranlar\u0131 1.5\/2, 0.38-4 \u00b5g\/ml \u015feklinde saptam\u0131\u015flard\u0131r. \u00c7al\u0131\u015fmam\u0131zda da M\u0130K50<\/sub>\/ M\u0130K90 <\/sub>de\u011ferleri \u00e7ok merkezli \u00e7al\u0131\u015fmalarla benzer ama son y\u0131llarda bildirilen \u00e7al\u0131\u015fmalardan y\u00fcksek bulunmu\u015ftur. Ulusal Antimikrobiyal Diren\u00e7 S\u00fcrveyans Sistemi (UAMDSS) 2016 ve Orta Asya ve Avrupa Antimikrobiyal Diren\u00e7 S\u00fcrveyans\u0131 (Central Asian and European Surveillance of Antimicrobial Resistance\u00a0 – CAESAR) <\/span>2019 verilerinde \u00fclkemizde MRSA su\u015flar\u0131nda vankomisin direnci bildirilmemi\u015ftir (21,22). M\u0130K50<\/sub>, M\u0130K90<\/sub> de\u011ferleri ve M\u0130K aral\u0131klar\u0131 farkl\u0131 b\u00f6lgelerde, farkl\u0131 hastanelerde ve farkl\u0131 zamanlarda farkl\u0131 bulunabilmektedir. Fakat \u00e7al\u0131\u015fmam\u0131zdan farkl\u0131 olarak \u00fclkemizde MRSA izolat\u0131nda %21.3 gibi oranlarda heterojen vankomisine orta duyarl\u0131 S. aureus<\/em> (hVISA) varl\u0131\u011f\u0131 tespit edilen \u00e7al\u0131\u015fmalar da bildirilmeye devam etmektedir (23). Bu izolatlar\u0131n\u0131n rutin antimikrobiyal duyarl\u0131l\u0131k testleriyle belirlenememesi ve vankomisinin olduk\u00e7a yayg\u0131n kullan\u0131lmas\u0131, \u00fclkemizde belirli aral\u0131klarla azalm\u0131\u015f vankomisin duyarl\u0131l\u0131\u011f\u0131n\u0131n ara\u015ft\u0131r\u0131lmas\u0131n\u0131 gerekli k\u0131lmaktad\u0131r (23). \u00c7al\u0131\u015fmam\u0131zda MSSA izolatlar\u0131nda saptanan M\u0130K50<\/sub>\/M\u0130K90<\/sub> de\u011ferlerinin (1 \u00b5g\/ml\/1.5 \u00b5g\/ml) MRSA de\u011ferlerine yak\u0131n bulunmas\u0131, M\u0130K aral\u0131\u011f\u0131n\u0131n MRSA i\u00e7in bulunanlarla e\u015fit saptanmas\u0131 (0.38-2 \u00b5g\/ml) ve MSSA izolatlar\u0131n\u0131n M\u0130K 1\u00b5g\/ml ve 1.5 \u00b5g\/ml de\u011ferlerinde yo\u011funla\u015fmas\u0131 metisiline duyarl\u0131 izolatlarda M\u0130K de\u011ferlerinin y\u00fckseldi\u011fini g\u00f6stermektedir. Vankomisin M\u0130K de\u011ferleri y\u00fcksek su\u015flarla infekte hastalar\u0131n tedavi ba\u015far\u0131lar\u0131n\u0131n d\u00fc\u015f\u00fck oldu\u011fu ve mortalitenin y\u00fckseldi\u011fi bilinmektedir. Ayr\u0131ca VISA su\u015flar\u0131n\u0131n vankomisin tedavisi s\u0131ras\u0131nda ortaya \u00e7\u0131kabildi\u011fi unutulmamal\u0131d\u0131r (13). Vankomisin M\u0130K de\u011ferlerinde saptanan y\u00fckselmenin hastanemiz i\u00e7in gelecekte sorun olabilece\u011fi d\u00fc\u015f\u00fcn\u00fclmektedir.<\/p>\n

Teikoplanin, etki mekanizmas\u0131 olarak vankomisine benzemesi ve d\u00fc\u015f\u00fck yan etki g\u00f6stermesiyle vankomisine alternatif olarak kullan\u0131lan bir glikopeptiddir. MRSA tedavisinde uzun s\u00fcreli kullan\u0131m durumunda teikoplanine diren\u00e7 geli\u015febildi\u011fine dair yay\u0131nlar vard\u0131r (8). \u00c7al\u0131\u015fmam\u0131zda \u00fclkemiz s\u00fcrveyans verileriyle uyumlu olarak teikoplanine diren\u00e7 saptanmam\u0131\u015ft\u0131r (22). Teikoplanin M\u0130K50<\/sub>, M\u0130K90<\/sub> de\u011ferleri ve M\u0130K aral\u0131klar\u0131 s\u0131ras\u0131yla MRSA i\u00e7in 1.5\/2, 0.125-2 \u00b5g\/ml; MSSA i\u00e7in 0.75\/1.5, 0.125-2 \u00b5g\/ml saptanm\u0131\u015ft\u0131r. Bu de\u011ferler Yeni\u015fehirli ve arkada\u015flar\u0131 (13)\u2019n\u0131n \u00e7al\u0131\u015fmalar\u0131yla benzer bulunurken \u00c7elikbilek ve arkada\u015flar\u0131 (18), Ho\u015fbul ve arkada\u015flar\u0131 (4) ve \u00c7\u0131kman ve arkada\u015flar\u0131 (20)\u2019n\u0131n \u00e7al\u0131\u015fmalar\u0131ndan d\u00fc\u015f\u00fck bulunmu\u015ftur. Bu de\u011ferler hastanemizde teikoplaninin vankomisine nazaran daha az kullan\u0131lmas\u0131na ba\u011fl\u0131 olabilece\u011fiyle ili\u015fkilendirilmi\u015ftir.<\/p>\n

Linezolid, \u00f6zellikle MRSA kaynakl\u0131 deri ve yumu\u015fak doku infeksiyonlar\u0131n\u0131n ve toplum\/hastane k\u00f6kenli pn\u00f6moni infeksiyonlar\u0131n\u0131n tedavisinde farkl\u0131 etki mekanizmas\u0131yla, k\u0131sa s\u00fcreli g\u00fcvenli kullan\u0131m\u0131yla vankomisin direncinin artmas\u0131n\u0131 engelleme amac\u0131yla kullan\u0131labilen bir ajand\u0131r (15). Her ne kadar g\u00fcn\u00fcm\u00fczde yurtd\u0131\u015f\u0131ndaki baz\u0131 \u00e7al\u0131\u015fmalarda linezolide diren\u00e7li MRSA su\u015flar\u0131 g\u00f6sterilmi\u015fse de (24), \u00fclkemizde ve bizim \u00e7al\u0131\u015fmam\u0131zda MRSA su\u015flar\u0131nda linezolid direncine rastlanmam\u0131\u015ft\u0131r (10,15,21). \u00c7al\u0131\u015fmam\u0131zda linezolid M\u0130K50<\/sub>\/M\u0130K90<\/sub> de\u011ferleri MRSA i\u00e7in 0.75\/1.5 \u00b5g\/ml, MSSA i\u00e7in 0.75\/1 \u00b5g\/ml; M\u0130K de\u011fer aral\u0131klar\u0131 0.25-2 \u00b5g\/ml olarak bulunmu\u015ftur. \u00dclkemizden bildirilen 2011 y\u0131l\u0131ndaki \u00e7al\u0131\u015fmada (18) bulunan M\u0130K50<\/sub>\/M\u0130K90<\/sub> de\u011ferleri olduk\u00e7a d\u00fc\u015f\u00fck iken y\u0131llar i\u00e7erisinde bildirilen \u00e7al\u0131\u015fmalarda bu de\u011ferlerin de\u011fi\u015fen oranlarda ama daha y\u00fcksek bulundu\u011fu, M\u0130K aral\u0131\u011f\u0131n\u0131n ise de\u011fi\u015febildi\u011fi g\u00f6zlemlenmi\u015ftir (4,13,20). \u00c7al\u0131\u015fmam\u0131zda MRSA ve MSSA\u2019larda ayn\u0131 M\u0130K aral\u0131\u011f\u0131n\u0131n saptanmas\u0131 ve MSSA izolatlar\u0131n\u0131n MRSA izolatlar\u0131nda oldu\u011fu gibi ayn\u0131 M\u0130K de\u011ferlerinde yo\u011funla\u015fmas\u0131, izolatlar\u0131m\u0131z\u0131n linezolid M\u0130K art\u0131\u015f\u0131n\u0131n metisilin direncinden ba\u011f\u0131ms\u0131z olarak y\u00fckselebildi\u011fini d\u00fc\u015f\u00fcnd\u00fcrm\u00fc\u015ft\u00fcr. \u00dclkemizdeki \u00e7e\u015fitli \u00e7al\u0131\u015fmalarda \u00e7al\u0131\u015fmam\u0131za benzer \u015fekilde linezolid direnci saptanmam\u0131\u015ft\u0131r (13,20,25,26). Ulusal s\u00fcrveyans verilerimizde ve CAESAR 2019 verilerinde de \u00fclkemizde MRSA su\u015flar\u0131nda linezolid direnci bildirilmemi\u015ftir (21,22). Amerika Birle\u015fik Devletleri (ABD)\u2019nde ger\u00e7ekle\u015ftirilen geni\u015f \u00e7apl\u0131 bir s\u00fcrveyans \u00e7al\u0131\u015fmas\u0131nda MSSA su\u015flar\u0131nda linezolid direncine rastlanmazken MRSA su\u015flar\u0131nda %0.1 oran\u0131nda diren\u00e7 tespit edilmi\u015ftir (27). Avrupa Antimikrobiyal Diren\u00e7 S\u00fcrveyans A\u011f\u0131 (<\/span>European Antimicrobial Resistance Surveillance Network – EARS-Net) 2015 raporunda Avrupa \u00fclkelerinde de benzer \u015fekilde S. aureus <\/em>su\u015flar\u0131nda linezolid direnci %0.1 olarak bildirilmi\u015ftir (28).<\/p>\n

Daptomisin, hem \u00fcreme faz\u0131ndaki, hem de dura\u011fan fazdaki Gram-pozitif bakterilere etkili siklik bir lipopeptiddir (18). \u00c7al\u0131\u015fmam\u0131zda MRSA izolatlar\u0131nda daptomisin direnci %3 ve kinupristin\/dalfopristin direnci %4 olarak saptanm\u0131\u015f, glikopeptidler ve linezolidden sonraki en etkili antibiyotikler olarak tespit edilmi\u015flerdir. Uluslararas\u0131 \u00e7al\u0131\u015fmalarda daptomisin direncine ba\u011fl\u0131 tedavi ba\u015far\u0131s\u0131zl\u0131\u011f\u0131 bildirilmeye ba\u015flam\u0131\u015ft\u0131r (29). Yeni\u015fehirli ve arkada\u015flar\u0131, daptomisine direnci %2 olarak bildirirken di\u011fer \u00e7al\u0131\u015fmalarda diren\u00e7 bildirilmemi\u015ftir (18,20,30,31). \u00dclkemizde klinik kullan\u0131m\u0131 olmayan kinupristin\/dalfopristin direncine rastlanmam\u0131\u015ft\u0131r (13,15,20).<\/p>\n

\u00c7al\u0131\u015fmam\u0131zda kotrimoksazol diren\u00e7 oranlar\u0131 MRSA izolatlar\u0131nda %11, MSSA izolatlar\u0131nda %2 olarak tespit edilmi\u015ftir. \u00dclkemizde yap\u0131lan farkl\u0131 \u00e7al\u0131\u015fmalarda MRSA i\u00e7in %4-74, MSSA i\u00e7in %1-89 aras\u0131nda bildirilmi\u015ftir (25,26,30,32). MRSA izolatlar\u0131 i\u00e7in bile saptanan d\u00fc\u015f\u00fck oranlardaki diren\u00e7, ya\u015famsal risk ta\u015f\u0131mayan S. aureus <\/em>infeksiyonlar\u0131n\u0131n ampirik tedavisinde kotrimoksazol\u00fcn alternatif bir antibiyotik olarak kullan\u0131labilece\u011fini g\u00f6stermektedir.<\/p>\n

Fusidik asid, S. aureus<\/em>\u2019lar\u0131n etken oldu\u011fu \u00f6zellikle deri, yumu\u015fak doku, kemik ve eklem infeksiyonlar\u0131nda glikopeptidlere alternatif olarak kullan\u0131labilen bir antibiyotiktir (26). \u00dclkemizde yap\u0131lan \u00e7al\u0131\u015fmalarda, fusidik asid direnci MRSA izolatlar\u0131 i\u00e7in %3-20, MSSA i\u00e7in %3-7 aras\u0131nda bildirilmi\u015ftir (15,26,30). \u00c7al\u0131\u015fmam\u0131zda saptanan fusidik asid direnci MRSA su\u015flar\u0131nda %20 ile \u00fclkemiz \u00e7al\u0131\u015fmalar\u0131ndan daha y\u00fcksek iken, MSSA su\u015flar\u0131nda %5 ile benzer bulunmu\u015ftur. Bu nedenle glikopeptid direncinin \u00f6nlenmesi i\u00e7in kullan\u0131lan fusidik asidin MRSA infeksiyonlar\u0131nda daha dikkatli kullan\u0131lmas\u0131 gerekti\u011fi sonucuna var\u0131lm\u0131\u015ft\u0131r.<\/p>\n

\u201cTigecycline Evaluation and Surveillance Trial\u201d (TEST) \u00e7al\u0131\u015fmas\u0131nda tigesiklinin hem Gram-pozitif hem de Gram-negatif bakteriler i\u00e7in \u00e7ok y\u00fcksek antibakteriyel etkiye sahip oldu\u011fu bildirilmi\u015ftir (33). \u00c7al\u0131\u015fmam\u0131zda MSSA su\u015flar\u0131nda tigesikline diren\u00e7 saptanmazken MRSA su\u015flar\u0131nda %9 diren\u00e7 saptanm\u0131\u015ft\u0131r. \u00dclkemizde tigesiklinin kullan\u0131ma girdi\u011fi ilk y\u0131llarda, hastalarda kullan\u0131m s\u00f6z konusu olmad\u0131\u011f\u0131 durumlarda da diren\u00e7 bildirimi olmu\u015ftur (31). Son y\u0131llardaki \u00e7al\u0131\u015fmalarda, diren\u00e7 saptanmayan \u00e7al\u0131\u015fmalar olmakla birlikte farkl\u0131 oranlarda diren\u00e7 bildirilen \u00e7al\u0131\u015fmalarda mevcuttur (5,14,30,34). \u00c7al\u0131\u015fmam\u0131zdaki y\u00fcksek tigesiklin direnci, bu ajan\u0131n hastanemizdeki kullan\u0131m\u0131nda dikkatli olunmas\u0131 gerekti\u011fini g\u00f6stermektedir.<\/p>\n

Kinolonlar geni\u015f antibakteriyel spektrumlar\u0131, gastrointestinal sistemden iyi emilimi ve iyi doku da\u011f\u0131l\u0131m\u0131 nedeniyle geni\u015f bir kullan\u0131m alan\u0131na sahiptir (25). \u00c7al\u0131\u015fmam\u0131zda MRSA su\u015flar\u0131nda siprofloksasin ve levofloksasin direnci %36 ve %57, MSSA su\u015flar\u0131nda ise %3 ve %9 olarak bulunmu\u015ftur. \u00dclkemizde yap\u0131lan farkl\u0131 \u00e7al\u0131\u015fmalarda siprofloksasin direnci MRSA su\u015flar\u0131nda %35-70, MSSA su\u015flar\u0131nda %4-7 olarak bildirilmi\u015ftir (15,25,26). MRSA su\u015flar\u0131nda ulusal s\u00fcrveyans verilerimizde %14.5, CAESAR 2019 verilerinde ise \u00fclkemizde %14 florokinolon direnci bildirilmi\u015ftir (21,22). Hastanemizde kinolonlar MSSA izolatlar\u0131nda iyi bir alternatif iken MRSA izolatlar\u0131nda olduk\u00e7a diren\u00e7li bulundu\u011fundan kullan\u0131lmas\u0131 \u00f6nerilmemektedir. Ayr\u0131ca \u00e7al\u0131\u015fmam\u0131zdaki MRSA izolatlar\u0131nda gentamisin, rifampisin, eritromisin, klindamisin ve tetrasikline kar\u015f\u0131 olduk\u00e7a y\u00fcksek diren\u00e7 oranlar\u0131 saptanmas\u0131 nedeniyle bu su\u015flarda kullan\u0131lmas\u0131 \u00f6nerilmemekte, MSSA su\u015flar\u0131nda ise bu ajanlar h\u00e2l\u00e2 iyi bir alternatif olarak g\u00f6z\u00fckmektedir.<\/p>\n

Sonu\u00e7 olarak, \u00e7al\u0131\u015fmam\u0131zda vankomisin, teikoplanin, linezolide kar\u015f\u0131 MRSA ve MSSA izolatlar\u0131nda diren\u00e7 saptanmam\u0131\u015ft\u0131r. Ancak, MSSA izolatlar\u0131n\u0131n glikopeptidlere kar\u015f\u0131 belirlenen M\u0130K de\u011ferlerinin, MRSA izolatlar\u0131n\u0131n M\u0130K de\u011ferlerine yak\u0131n de\u011ferlerde saptanmas\u0131 gelecekte diren\u00e7 geli\u015fimi olas\u0131l\u0131\u011f\u0131n\u0131n artaca\u011f\u0131n\u0131 d\u00fc\u015f\u00fcnd\u00fcrm\u00fc\u015f, M\u0130K de\u011ferlerinin d\u00fczenli olarak takip edilmesinin gereklili\u011fini g\u00f6stermi\u015ftir. Linezolid M\u0130K90 <\/sub>de\u011ferlerine g\u00f6re glikopeptid ajanlardan daha etkin bulunmu\u015ftur. Ancak linezolide kar\u015f\u0131 M\u0130K y\u00fckselmesine dikkat edilmesi gerekmektedir. Ayr\u0131ca di\u011fer antibiyotikler MSSA su\u015flar\u0131nda olduk\u00e7a etkin iken MRSA su\u015flar\u0131nda daha dikkatli kullan\u0131lmas\u0131 gerekti\u011fi d\u00fc\u015f\u00fcn\u00fclmektedir. Otomatize sistemlerle glikopeptid veya linezolide diren\u00e7li saptanan S. aureus <\/em>izolatlar\u0131 mutlaka referans bir y\u00f6ntemle do\u011frulanmal\u0131d\u0131r. Gerekli infeksiyon kontrol \u00f6nlemleriyle birlikte hastane diren\u00e7 profillerinin d\u00fczenli olarak takip edilmesi, tedavi se\u00e7eneklerinin g\u00fcncellenmesi ve hastanelerin k\u0131s\u0131tl\u0131 antibiyotik kullan\u0131m politikalar\u0131n\u0131n daha s\u0131k\u0131 uygulanmas\u0131 vurgulanmaktad\u0131r.<\/p>\n","protected":false},"excerpt":{"rendered":"

\u00a0G\u0130R\u0130\u015e Staphylococcus aureus, bakteriyemi, infektif endokardit, deri ve yumu\u015fak doku infeksiyonlar\u0131n\u0131n ve osteoartrik\u00fcler infeksiyonlar\u0131n ba\u015fl\u0131ca etkeni olup hem toplum kaynakl\u0131 hem de hastane kaynakl\u0131 infeksiyonlara yol a\u00e7abilmektedir (1). Bu bakteri modern antibiyotik \u00e7a\u011f\u0131n\u0131n ba\u015f\u0131ndan bu yana antistafilokokal ila\u00e7lar\u0131n t\u00fcm\u00fcne kar\u015f\u0131 ilerleyici bir diren\u00e7 geli\u015ftirme yetene\u011fi sergilemi\u015ftir (2,3). Stafilokoklar\u0131n metisilin ve di\u011fer penisilinaza diren\u00e7li penisilinlerin kullan\u0131m\u0131n\u0131 […]<\/p>\n","protected":false},"author":2,"featured_media":22706,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[5169,5171,5170,3981,2985],"class_list":["post-22132","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ozgun-arastirma","tag-gradyan-test","tag-linezolid-2","tag-staphylococcus-aureus-2","tag-teikoplanin","tag-vankomisin"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/22132","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=22132"}],"version-history":[{"count":4,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/22132\/revisions"}],"predecessor-version":[{"id":22922,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/22132\/revisions\/22922"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/22706"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=22132"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=22132"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=22132"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}