{"id":25277,"date":"2022-08-22T16:43:32","date_gmt":"2022-08-22T13:43:32","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=25277"},"modified":"2022-11-02T14:48:54","modified_gmt":"2022-11-02T11:48:54","slug":"karbapeneme-direncli-enterobacteriaceae","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2022\/08\/22\/karbapeneme-direncli-enterobacteriaceae\/","title":{"rendered":"Karbapeneme Diren\u00e7li Enterobacteriaceae<\/i> D\u0131\u015fk\u0131 Kolonizasyonunun Belirlenmesinde Klasik Y\u00f6ntemler ve Kromojen Agar Testinin Kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131"},"content":{"rendered":"

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

Son y\u0131llarda \u00fclkemizde gittik\u00e7e artan s\u0131kl\u0131kta g\u00f6r\u00fclmekte olan karbapeneme diren\u00e7li Enterobacteriaceae <\/i>(KDE) <\/i>infeksiyonlar\u0131, daha \u00e7ok komorbiditeleri olan ve yo\u011fun sa\u011fl\u0131k bak\u0131m\u0131 uygulanan hastalarda ortaya \u00e7\u0131kmaktad\u0131r. KDE\u2019ler, ciddi infeksiyonlara neden olarak hem y\u00fcksek mortalite ve morbiditeye yol a\u00e7makta hem de hastanede yat\u0131\u015f s\u00fcresini uzatarak maliyetleri \u00f6nemli \u00f6l\u00e7\u00fcde art\u0131rmaktad\u0131r (1). Gram-negatif \u00e7omaklarda karbapenem direnci \u015fu mekanizmalar\u0131n biri veya birka\u00e7\u0131n\u0131n birlikte olmas\u0131yla ortaya \u00e7\u0131kar: \u03b2-laktamaz (karbapenemaz) \u00fcretimi, belli d\u0131\u015f membran proteinlerinin (porin) kayb\u0131 sonras\u0131 geli\u015fen permeabilite azalmas\u0131 veya ilac\u0131n d\u0131\u015f membrandan pompalanmas\u0131 (efluks). KDE su\u015flar\u0131 sadece \u03b2-laktamlara de\u011fil, di\u011fer bir\u00e7ok antibiyotik s\u0131n\u0131f\u0131na kar\u015f\u0131 da diren\u00e7 g\u00f6sterir (2).\u00a0<\/span><\/p>\n

KDE infeksiyonlar\u0131n\u0131n sa\u011fl\u0131k kurulu\u015flar\u0131nda bulunan hastalar aras\u0131nda bula\u015fmas\u0131nda, ana kayna\u011f\u0131n KDE ile kolonize hastalar oldu\u011fu bilinmektedir. Bu nedenle kolonize hastalar\u0131n, \u00f6zellikle rektal s\u00fcr\u00fcnt\u00fc yoluyla al\u0131nan tarama k\u00fclt\u00fcrleriyle belirlenerek uygun \u015fekilde izole edilmesi infeksiyonlar\u0131n kontrol\u00fcndeki en \u00f6nemli basamakt\u0131r. Ancak tarama k\u00fclt\u00fcrlerinin ne \u015fekilde yap\u0131laca\u011f\u0131 konusunda halen bir g\u00f6r\u00fc\u015f birli\u011fi olu\u015fmam\u0131\u015ft\u0131r (2). \u00c7al\u0131\u015fman\u0131n amac\u0131, hastanede yatan hastalar\u0131n d\u0131\u015fk\u0131s\u0131nda KDE kolonizasyonunun belirlenmesinde klasik y\u00f6ntemlerle kromojenik agar kullan\u0131lan y\u00f6ntemlerin kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131d\u0131r.<\/p>\n

Y\u00d6NTEMLER<\/h2>\n

Hastalar\u0131n Se\u00e7imi ve Verilerin Toplanmas\u0131<\/h3>\n

\u00c7al\u0131\u015fmam\u0131z, Ocak ve A\u011fustos 2017 tarihleri aras\u0131nda bir \u00fcniversite hastanesinde bulunan Reanimasyon Yo\u011fun Bak\u0131m \u00dcnitesi (YB\u00dc) ve Acil Cerrahi YB\u00dc\u2019de y\u00fcr\u00fct\u00fcld\u00fc. Reanimasyon YB\u00dc\u2019de 15 yatak, Acil Cerrahi YB\u00dc\u2019de ise 10 yatak bulunmaktayd\u0131. \u00c7al\u0131\u015fma tarihleri aras\u0131nda, belirtilmi\u015f YB\u00dc\u2019lerde yatan ve 18 ya\u015f\u0131ndan b\u00fcy\u00fck olan ard\u0131\u015f\u0131k 100 hasta \u00e7al\u0131\u015fmaya dahil edildi. Hastalar\u0131n demografik, klinik ve laboratuvar bilgileri, kendileriyle konu\u015farak, dosyalar\u0131ndan ve hastanenin veritaban\u0131ndan elde edildi. Daha \u00f6nceden geli\u015ftirilen bir forma; hastalar\u0131n ya\u015f\u0131, cinsiyeti, yatt\u0131\u011f\u0131 YB\u00dc (acil cerrahi ya da reanimasyon), komorbiditeleri ve bundan yola \u00e7\u0131k\u0131larak Charlson komorbidite indeksi, YB\u00dc\u2019ye yatmadan 3 ve 6 ay \u00f6ncesine kadarki hastane yat\u0131\u015flar\u0131 ve antibiyotik kullan\u0131m \u00f6yk\u00fcs\u00fc, YB\u00dc\u2019ye yatt\u0131\u011f\u0131 g\u00fcn ba\u015flanm\u0131\u015f olan antibiyotikler ve almakta oldu\u011fu imm\u00fcnos\u00fcpresif tedaviler, yat\u0131\u015fta ba\u015flanm\u0131\u015f proton pompa inhibit\u00f6rleri (PPI) ve\u00a0 <\/span>non-steroid antiinflamatuar ila\u00e7 (NSAID) kullan\u0131m\u0131, yatt\u0131\u011f\u0131 g\u00fcnk\u00fc kan l\u00f6kosit ve trombosit say\u0131s\u0131, hemoglobin, serum kreatinin, ALT ve alb\u00fcmin de\u011ferleri kaydedildi.\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fmaya dahil edilen hastalar\u0131n t\u00fcm\u00fcnden, ba\u015fvuru an\u0131nda ve ba\u015fvurudan sonra YB\u00dc\u2019de yatt\u0131\u011f\u0131 s\u00fcre boyunca\u00a0 <\/span>birer hafta\u00a0 <\/span>arayla rektal s\u00fcr\u00fcnt\u00fc \u00f6rne\u011fi al\u0131nd\u0131. KDE ta\u015f\u0131y\u0131c\u0131l\u0131\u011f\u0131 belirlenen\u00a0 <\/span>hastalarda, KDE saptanan ilk rektal s\u00fcr\u00fcnt\u00fc; KDE ta\u015f\u0131y\u0131c\u0131s\u0131 olmayan hastalarda, YB\u00dc\u2019den \u00e7\u0131kmadan \u00f6nceki son rektal s\u00fcr\u00fcnt\u00fc \u00f6rne\u011fi de\u011ferlendirildi. Hastalar\u0131n rektal s\u00fcr\u00fcnt\u00fcleri ve infeksiyon d\u00fc\u015f\u00fcn\u00fcld\u00fc\u011f\u00fc zaman al\u0131nm\u0131\u015f di\u011fer v\u00fccut \u00f6rneklerinde (balgam, plevral s\u0131v\u0131, periton s\u0131v\u0131s\u0131, idrar vb.) KDE varl\u0131\u011f\u0131 ara\u015ft\u0131r\u0131ld\u0131.<\/span><\/p>\n

Hastalar\u0131n yatt\u0131\u011f\u0131 iki YB\u00dc\u2019de de yatan hasta, KDE ile kolonize hasta ve\u00a0 <\/span>dolu-bo\u015f yatak say\u0131lar\u0131 g\u00fcnl\u00fck olarak kaydedildi; bu verilerden YB\u00dc\u2019lerde kolonizasyon bas\u0131nc\u0131 y\u00fczde olarak hesapland\u0131. Kolonizasyon bas\u0131nc\u0131n\u0131n hesaplanmas\u0131nda a\u015fa\u011f\u0131daki form\u00fcl kullan\u0131ld\u0131:<\/p>\n

KOLON\u0130ZASYON BASINCI =YB\u00dc\u2019de o g\u00fcn yatmakta olan KDE-pozitif hastalar\u0131n yatt\u0131\u011f\u0131 yatak say\u0131s\u0131 \/ YB\u00dc\u2019de hastalar\u0131n yatt\u0131\u011f\u0131 toplam yatak say\u0131s\u0131 X 100\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fma prospektif kohort olarak planland\u0131 ve \u0130stanbul \u00dcniversitesi T\u0131p Fak\u00fcltesi Klinik Ara\u015ft\u0131rmalar Etik Kurulu\u2019ndan 10 Haziran 2016 tarih ve 778 karar numaras\u0131yla onay al\u0131nd\u0131.\u00a0<\/span><\/p>\n

Rektal S\u00fcr\u00fcnt\u00fc \u00d6rneklerinin \u00c7al\u0131\u015f\u0131lmas\u0131<\/h3>\n

Gelen t\u00fcm rektal s\u00fcr\u00fcnt\u00fc \u00f6rneklerinin 0.5 ml fizyolojik serum i\u00e7inde s\u00fcspansiyonlar\u0131 haz\u0131rland\u0131. Pipetle al\u0131nan 50 \u03bcl\u2019lik 3 ayr\u0131 s\u00fcspansiyon \u00f6rne\u011fi, a\u015fa\u011f\u0131da belirtilen 3 ayr\u0131 y\u00f6ntemle i\u015fleme al\u0131nd\u0131:<\/p>\n

CDC Taraf\u0131ndan \u00d6nerilen Klasik Y\u00f6ntemin Modifikasyonu (Klasik CDC)<\/i>:<\/b> <\/span>5 ml triptik soya buyyonu (TSB) bulunan t\u00fcplere ekim yap\u0131ld\u0131 ve buyyon i\u00e7ine bir adet 10 \u03bcg ertapenem diski konuldu. 18-24 saat aras\u0131nda 37 \u00b0C s\u0131cakl\u0131\u011f\u0131ndaki et\u00fcvde ink\u00fcbe edildi. TSB\u2019de bulan\u0131kl\u0131k olup olmad\u0131\u011f\u0131 24. saatte kaydedildi; bulan\u0131kl\u0131k olan ve olmayan t\u00fcm \u00f6rneklerin MacConkey agar\u0131na pasajlar\u0131 yap\u0131ld\u0131. Bu \u00f6rnekler de 18-24 saatlik bir s\u00fcre boyunca ink\u00fcbe edildi. MacConkey agar\u0131nda \u00fcreyen ve laktoz-pozitif olan (pembe-k\u0131rm\u0131z\u0131 renk) koloniler varsa, bu bakterilere ileri idantifikasyon ve disk dif\u00fczyon y\u00f6ntemiyle 48. saatte antibiyogram yap\u0131ld\u0131 (4).<\/p>\n

\"\"<\/a>

Resim 1.<\/strong> PMacConkey agar\u0131na direkt olarak ekilip ertapenem (ETP) diski konulmu\u015f \u00f6rneklerden karbapeneme diren\u00e7li Enterobacteriaceae<\/i> (KDE) \u00fcremi\u015f olanlar\u0131n ilk 24. saatteki g\u00f6r\u00fcn\u00fcm\u00fc (ETP diski \u00e7evresinde \u00fcremi\u015f ve olas\u0131 karbapeneme diren\u00e7li K. pneumoniae<\/i> olarak de\u011ferlendirilmi\u015f okla g\u00f6sterilen koloniler, idantifikasyonla karbapeneme diren\u00e7li K. pneumoniae<\/i> olarak tan\u0131mlanm\u0131\u015ft\u0131r).<\/p><\/div>\n

MacConkey Agar\u0131na Direkt Ekim Y\u00f6ntemi (Direkt McConkey)<\/i>:<\/b> <\/span>MacConkey agar\u0131na direkt ekim yap\u0131l\u0131p, besiyerinde ekim yap\u0131lan b\u00f6lgeye 10 \u03bcg ertapenem diski yerle\u015ftirildi.\u00a0 <\/span>18-24 saat aras\u0131nda 37 \u00b0C s\u0131cakl\u0131\u011f\u0131ndaki et\u00fcvde ink\u00fcbe edildi. Ertapenem diski i\u00e7inde \u00fcreyen laktoz-pozitif koloniler varsa, bu bakterilere ileri idantifikasyon ve disk dif\u00fczyon y\u00f6ntemiyle 24. saatte antibiyogram yap\u0131ld\u0131 (6, 7) (Resim 1).<\/p>\n

\"\"<\/a>

Resim 2.<\/strong> ChromID CARBA agar\u0131na direkt olarak ekilmi\u015f \u00f6rneklerden karbapeneme diren\u00e7li Enterobacteriaceae <\/i> (KDE) \u00fcremi\u015f olanlar\u0131n ilk 24. saatteki g\u00f6r\u00fcn\u00fcm\u00fc (Olas\u0131 karbapeneme diren\u00e7li K. pneumoniae<\/i> olarak de\u011ferlendirilmi\u015f okla g\u00f6sterilen ye\u015fil-mavi renkli koloniler, idantifikasyonla karbapeneme diren\u00e7li K. pneumoniae<\/i> olarak tan\u0131mlanm\u0131\u015ft\u0131r).<\/p><\/div>\n

Kromojenik Agara Direkt Inok\u00fclasyon Y\u00f6ntemi (ChromID CARBA):<\/i><\/b>\u00a0 <\/span><\/span>ChromID CARBA\u00ae<\/sup> (bioM\u00e9rieux, Marcy l\u2019Etoile, Fransa) agar\u0131na direkt ekim yap\u0131ld\u0131. Ekilen \u00f6rnekler 18-24 saat aras\u0131 37 \u00b0C s\u0131cakl\u0131\u011f\u0131ndaki et\u00fcvde ink\u00fcbe edildi. Besiyerindeki \u00fcremeler 24. saatte kontrol edildi. Ye\u015fil-mavi renkli koloniler, olas\u0131 karbapeneme diren\u00e7li Klebsiella pneumoniae<\/i>; mor-k\u0131rm\u0131z\u0131 renkli koloniler olas\u0131 karbapeneme diren\u00e7li Escherichia coli<\/i>; renksiz koloniler ise olas\u0131 karbapeneme diren\u00e7li Gram-negatif nonfermentatif \u00e7omak (Pseudomonas aeruginosa<\/i> veya Acinetobacter baumannii<\/i>) olarak de\u011ferlendirildi. Bu bakterilere ileri idantifikasyon ve disk dif\u00fczyon y\u00f6ntemiyle antibiyogram yap\u0131ld\u0131 (Resim 2).\u00a0<\/span><\/p>\n

\"\"<\/a>

Resim 3A ve 3B.<\/strong> Modifiye Hodge testinin uyguland\u0131\u011f\u0131 karbapeneme diren\u00e7li Enterobacteriaceae<\/i> (KDE) su\u015flar\u0131n\u0131n 24 saatlik ink\u00fcbasyondan sonraki g\u00f6r\u00fcn\u00fcm\u00fc (Resim 3A\u2019daki k\u0131rm\u0131z\u0131 halka bir su\u015ftaki pozitif sonucu g\u00f6stermektedir. Resim 3B\u2019de ise negatif sonu\u00e7 vermi\u015f \u00fc\u00e7 su\u015f g\u00f6r\u00fclmektedir).<\/p><\/div>\n

Rektal s\u00fcr\u00fcnt\u00fc \u00f6rneklerinden yukar\u0131da anlat\u0131lm\u0131\u015f y\u00f6ntemlerle izole edilen Enterobacteriaceae<\/i> su\u015flar\u0131n\u0131n t\u00fcm\u00fcne\u00a0 <\/span>modifiye Hodge testi (MHT) ve Kirby-Bauer y\u00f6ntemiyle disk dif\u00fczyon duyarl\u0131l\u0131k testi yap\u0131ld\u0131; sonu\u00e7lar EUCAST\u2019in \u00f6nerdi\u011fi s\u0131n\u0131r de\u011ferler kullan\u0131larak de\u011ferlendirildi (5, 8). MHT, ertapeneme duyarl\u0131 oldu\u011fu bilinen E. coli<\/i> ATCC 25922 referans su\u015fu kullan\u0131larak yap\u0131ld\u0131. Referans su\u015f 0.5 McFarland standard\u0131 bulan\u0131kl\u0131\u011f\u0131nda haz\u0131rlan\u0131p Mueller-Hinton agar\u0131na inok\u00fcle edildi; sonras\u0131nda agara 10 \u03bcg ertapenem diski konularak test edilecek su\u015flar, diskin kenar\u0131ndan agar\u0131n bulundu\u011fu Petri kab\u0131n\u0131n kenar\u0131na do\u011fru \u00e7izgi \u015feklinde ekildi.\u00a0 <\/span>En az 16 saatlik ink\u00fcbasyondan sonra su\u015flar kontrol edildi. Referans ATCC 25922 su\u015funun, ertapenem diskinin merkezine do\u011fru, yonca yapra\u011f\u0131 \u015feklinde girinti yapmas\u0131na neden olan\u00a0 <\/span>su\u015flar karbapenemaz-pozitif olarak kabul edildi (Resim 3A ve 3B). Bu test yap\u0131l\u0131rken CDC\u2019nin \u00f6nerilerinden yararlan\u0131ld\u0131 (8).<\/p>\n

Antibiyogramda amoksisilin\/klavulanat, sefepim, seftriakson, piperasilin\/tazobaktam, sefoksitin, seftazidim, meropenem, sefoperazon\/sulbaktam, imipenem, fosfomisin, kolistin, nitrofurantoin, ofloksasin, norfloksasin, ertapenem, trimetoprim\/s\u00fclfametoksazol, siprofloksasin, ampisilin\/sulbaktam, sefuroksim, gentamisin, netilmisin, amikasin ve aztreonam diskleri kullan\u0131ld\u0131.\u00a0<\/span><\/p>\n

Rektal s\u00fcr\u00fcnt\u00fclerden izole edilmi\u015f ve disk dif\u00fczyon testleriyle KDE oldu\u011fu belirlenmi\u015f su\u015flarda, Etest\u00ae<\/span> (bioM\u00e9rieux, Marcy l\u2019Etoile, Fransa) y\u00f6ntemiyle imipenem, ertapenem, meropenem ve kolistin i\u00e7in minimum inhibit\u00f6r konsantrasyonu (M\u0130K) de\u011ferleri belirlendi. \u00a0<\/span><\/p>\n

Bakterilerdeki metallo-\u03b2-laktamaz (MBL) varl\u0131\u011f\u0131n\u0131 g\u00f6stermek i\u00e7in imipenem-EDTA Etest\u00ae<\/span> (bioM\u00e9rieux, Marcy l\u2019Etoile, Fransa) de kullan\u0131ld\u0131.\u00a0 <\/span>\u00dcretici firman\u0131n \u00f6nerisi do\u011frultusunda imipenem \/ imipenem -EDTA M\u0130K de\u011ferleri analiz edilerek, EDTA\u2019l\u0131 k\u0131s\u0131mda M\u0130K de\u011ferinin 8 veya daha fazla kat azalmas\u0131 MBL \u00fcreten bakteri izolat\u0131 olarak de\u011ferlendirildi (9).<\/p>\n

Bakterilerdeki OXA-48 varl\u0131\u011f\u0131na i\u015faret etti\u011fi i\u00e7in, izole edilmi\u015f KDE su\u015flar\u0131nda temosilin direnci olup olmad\u0131\u011f\u0131 da ara\u015ft\u0131r\u0131ld\u0131. Bu ama\u00e7la temosilin Etest<\/span>\u00ae<\/span> (bioM\u00e9rieux, Marcy l\u2019Etoile, Fransa) kullan\u0131ld\u0131; M\u0130K de\u011feri >32 \u03bcg\/ml olarak belirlenen su\u015flarda, OXA-48 pozitifli\u011fi olabilece\u011fi d\u00fc\u015f\u00fcn\u00fcld\u00fc.<\/span><\/p>\n

Bakterilerin idantifikasyonunda klasik y\u00f6ntemler [\u201cTripple Sugar Iron\u201d (TSI) agar\u0131, \u201cMotility Indole Ornithine\u201d (MIO) besiyeri, sitrat ve \u00fcre besiyerlerinin kullan\u0131m\u0131 gibi] ve API 20E\u00ae<\/span> (bioM\u00e9rieux, Marcy l\u2019Etoile, Fransa) kiti kullan\u0131ld\u0131.\u00a0<\/span><\/p>\n

KDE oldu\u011fu belirlenen \u00f6rneklere, \u00fcreticinin \u00f6nerileri do\u011frultusunda CARBA-NP\u00ae<\/span> (bioM\u00e9rieux, Marcy l\u2019Etoile, Fransa) testi de yap\u0131larak karbapenemaz varl\u0131\u011f\u0131 ara\u015ft\u0131r\u0131ld\u0131.\u00a0 \u00a0<\/span><\/p>\n

\u0130statistiktiksel Analiz<\/h3>\n

Verilerin istatistiksel analizi, SPSS (\u201cStatistical Package for the Social Sciences\u201d) versiyon 23.0 program\u0131 (IBM Corp., Armonk, NY, ABD)\u00a0 kullan\u0131larak yap\u0131ld\u0131. Gruplar\u0131n kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131nda kategorik de\u011fi\u015fkenler i\u00e7in \u03c7\u00b2 ve Fisher kesin testi; s\u00fcrekli de\u011fi\u015fkenler i\u00e7in da\u011f\u0131l\u0131m normalse Student t testi, normal de\u011filse Mann-Whitney U testi kullan\u0131ld\u0131. Ba\u011f\u0131ms\u0131z risk fakt\u00f6rlerinin ara\u015ft\u0131r\u0131lmas\u0131 i\u00e7in lojistik regresyon analizi yap\u0131ld\u0131. P<\/i><0.05 de\u011feri istatistiksel olarak anlaml\u0131 olarak kabul edildi.\u00a0<\/span><\/p>\n

Y\u00f6ntemlerin performanslar\u0131 de\u011ferlendirilirken, her \u00fc\u00e7 y\u00f6ntemden birinde pozitiflik belirlenen \u00f6rneklerin k\u00fcm\u00fclatif sonucu, \u201calt\u0131n standart\u201d olarak al\u0131nd\u0131. \u00c7al\u0131\u015f\u0131lan y\u00f6ntemlerin duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fck de\u011ferleri a\u015fa\u011f\u0131daki form\u00fcllerle hesapland\u0131:\u00a0<\/span><\/p>\n

DUYARLILIK = S\u00f6z Konusu Y\u00f6ntemle Belirlenmi\u015f Ger\u00e7ek KDE Ta\u015f\u0131y\u0131c\u0131lar\u0131n\u0131n Say\u0131s\u0131 \/ T\u00fcm Y\u00f6ntemlerle Belirlenmi\u015f KDE Ta\u015f\u0131y\u0131c\u0131s\u0131 Olanlar\u0131n Say\u0131s\u0131 X 100\u00a0<\/span><\/p>\n

\u00d6ZG\u00dcLL\u00dcK = S\u00f6z Konusu Y\u00f6ntemle Belirlenmi\u015f Ger\u00e7ek KDE Ta\u015f\u0131y\u0131c\u0131s\u0131 Olmayanlar\u0131n Say\u0131s\u0131 \/ T\u00fcm Y\u00f6ntemlerle Belirlenmi\u015f KDE Ta\u015f\u0131y\u0131c\u0131s\u0131 Olmayanlar\u0131n Say\u0131s\u0131 X 100\u00a0<\/span><\/p>\n

BULGULAR<\/h2>\n

Rektal KDE Kolonizasyonu Olan ve Olmayan Hastalar\u0131n De\u011ferlendirilmesi<\/h3>\n

\u00c7al\u0131\u015fmam\u0131za her iki YB\u00dc\u2019de yatm\u0131\u015f olan toplam 100 hasta al\u0131nd\u0131. Hastalar\u0131n 63 (%63)\u2019\u00fc Reanimasyon YB\u00dc\u2019de, 37 (%37)\u2019si ise Acil Cerrahi YB\u00dc\u2019de\u00a0 <\/span>yatmaktayd\u0131. Hastalar\u0131n 39\u00a0 <\/span>(%39)\u2019u kad\u0131n, 61 (%61)\u2019i erkek olup, ya\u015f ortalamas\u0131 58\u2019di. Hastalar\u0131n YB\u00dc\u2019de ortalama yat\u0131\u015f s\u00fcresi 17 g\u00fcnd\u00fc. \u00c7al\u0131\u015fmaya kat\u0131lan hastalar\u0131n 46 (%46)\u2019s\u0131n\u0131n rektal s\u00fcr\u00fcnt\u00fc \u00f6rne\u011finde, kullan\u0131lan \u00fc\u00e7 y\u00f6ntemden en az biriyle KDE kolonizasyonu saptand\u0131. Rektal KDE ta\u015f\u0131y\u0131c\u0131l\u0131\u011f\u0131 olan 46 hastan\u0131n 4 (%8.7)\u2019\u00fc YB\u00dc\u2019ye yatt\u0131\u011f\u0131 g\u00fcnden itibaren kolonize olarak saptand\u0131. Bu d\u00f6rt hastan\u0131n 3\u2019\u00fc d\u0131\u015f merkezden YB\u00dc\u2019lerimize transfer edilmi\u015fken, kalan biri hastanemizin bir servisinden YB\u00dc\u2019ye transfer edilmi\u015fti. Geri kalan 42 hastan\u0131n ortalama rektal KDE kolonizasyonu geli\u015fme s\u00fcresi 9.6 g\u00fcn olup s\u0131n\u0131rlar\u0131 2-55 g\u00fcnd\u00fc. \u00c7al\u0131\u015fma s\u00fcresince, YB\u00dc\u2019lerde KDE kolonizasyon bas\u0131nc\u0131 ortalamas\u0131 %40 olup en d\u00fc\u015f\u00fck %11 ve en y\u00fcksek %72 olarak tespit edildi.<\/span><\/p>\n

Rektal Karbapeneme Diren\u00e7li Enterobacteriaceae<\/i> Saptama Y\u00f6ntemlerinin Sonu\u00e7lar\u0131<\/h3>\n
\"\"<\/a>

Tablo 1.<\/strong> Rektal Karbapeneme Diren\u00e7li Enterobacteriaceae<\/i> Saptama Y\u00f6ntemlerinin 24. Saatteki Duyarl\u0131l\u0131k ve \u00d6zg\u00fcll\u00fcklerinin De\u011ferlendirilmesi<\/p><\/div>\n

\"\"<\/a>

Tablo 2.<\/strong> Rektal Karbapeneme Diren\u00e7li Enterobacteriaceae <\/i> Saptama Y\u00f6ntemlerinin 48. ve 72. Saatteki Duyarl\u0131l\u0131k ve \u00d6zg\u00fcll\u00fcklerinin De\u011ferlendirilmesi<\/p><\/div>\n

\"\"<\/a>

Tablo 3.<\/strong> Rektal Karbapeneme Diren\u00e7li Enterobacteriaceae<\/i> Saptama Y\u00f6ntemlerinin 24., 48. ve 72. Saatteki Sonu\u00e7lar\u0131<\/p><\/div>\n

Klasik CDC y\u00f6ntemiyle, ilk 24 saat sonra TSB buyyondaki bulan\u0131kl\u0131\u011f\u0131n rektal KDE pozitifli\u011fi olarak de\u011ferlendirilmesi halinde; 46 rektal KDE-pozitif hastan\u0131n 36 (%78)\u2019s\u0131 pozitif, 54 rektal KDE-negatif hastan\u0131n ise 23 (%42)\u2019\u00fc negatif olarak saptand\u0131. Bu testin ilk 24 saatteki duyarl\u0131l\u0131\u011f\u0131 %78, \u00f6zg\u00fcll\u00fc\u011f\u00fc ise %42 olarak hesapland\u0131. Testin t\u00fcm a\u015famalar\u0131n\u0131n sonu\u00e7land\u0131r\u0131ld\u0131\u011f\u0131 72. saatte ise duyarl\u0131l\u0131k %78, \u00f6zg\u00fcll\u00fck ise %100\u2019d\u00fc <\/span>(Tablo 1-2-3).<\/span><\/p>\n

Direkt\u00a0 <\/span>MacConkey y\u00f6ntemiyle, ilk 24 saatte 46 KDE-pozitif hastan\u0131n 40 (%87)\u2019\u0131 pozitif, 54 KDE-negatif hastan\u0131n 43 (%80)\u2019\u00fc negatif olarak saptand\u0131; testin duyarl\u0131l\u0131\u011f\u0131 %87, \u00f6zg\u00fcll\u00fc\u011f\u00fc %80\u2019di. Testin t\u00fcm a\u015famalar\u0131n\u0131n sonu\u00e7land\u0131r\u0131ld\u0131\u011f\u0131 48. saatte ise duyarl\u0131l\u0131k %87, \u00f6zg\u00fcll\u00fck ise %100 olarak hesapland\u0131 (Tablo 1-2-3).<\/span><\/p>\n

ChromID CARBA y\u00f6nteminde, ilk 24 saatte 46 KDE-pozitif hastan\u0131n 42 (%91)\u2019si, 54 KDE-negatif \u00a0 <\/span>hastan\u0131n ise 53 (%98)\u2019\u00fc negatif olarak saptand\u0131; testin\u00a0 <\/span>duyarl\u0131l\u0131\u011f\u0131 %91, \u00f6zg\u00fcll\u00fc\u011f\u00fc ise %98\u2019di. Testin tamamland\u0131\u011f\u0131 48. saatte duyarl\u0131l\u0131k %91, \u00f6zg\u00fcll\u00fck %100 olarak hesapland\u0131 (Tablo 1-2-3).<\/p>\n

Rektal S\u00fcr\u00fcnt\u00fc \u00d6rneklerinden \u0130zole Edilen Karbapeneme Diren\u00e7li Bakteri Su\u015flar\u0131<\/h3>\n
\"\"<\/a>

Tablo 4.<\/strong> Rektal S\u00fcr\u00fcnt\u00fc \u00d6rneklerinden \u0130zole Edilmi\u015f Karbapeneme Diren\u00e7li Bakterilerin Da\u011f\u0131l\u0131m\u0131<\/p><\/div>\n

\u00c7al\u0131\u015f\u0131lan rektal \u00f6rneklerde en s\u0131k izole edilen\u00a0 <\/span>karbapeneme diren\u00e7li bakteriler, 46 hastadan izole edilen\u00a0 <\/span>Enterobacteriaceae<\/i> \u00fcyeleri ve 39 hastada saptanan K.<\/i> pneumoniae<\/i> idi. Be\u015f hastada E. coli<\/i>, iki hastada Enterobacter aerogenes<\/i>, bir hastada ise Citrobacter freundii<\/i> izole edildi. Dokuz hastan\u0131n d\u0131\u015fk\u0131s\u0131nda karbapeneme diren\u00e7li Gram-negatif nonfermentatif \u00e7omaklar saptand\u0131; bunlar\u0131n alt\u0131s\u0131\u00a0 <\/span>P<\/i>. aeruginosa<\/em>, \u00fc\u00e7\u00fc ise A. baumannii<\/i> idi (Tablo 4).\u00a0<\/span><\/p>\n

\u00dcreyen Enterobactericeae<\/i> Su\u015flar\u0131n\u0131n Karbapenem M\u0130K De\u011ferleri, CARBA NP Testi ve MHT Sonu\u00e7lar\u0131<\/h3>\n
\"\"<\/a>

Tablo 5.<\/strong> \u0130zole Edilmi\u015f Karbapeneme Diren\u00e7li Enterobacteriaceae<\/i> Su\u015flar\u0131n\u0131n M\u0130K De\u011ferleri<\/p><\/div>\n

\u0130zole edilen su\u015flarda; temosilin, ertapenem, imipenem ve\u00a0 <\/span>meropenem Etest ile M\u0130K de\u011ferleri belirlendi. Ayr\u0131ca imipenem\/EDTA Etest ile MBL varl\u0131\u011f\u0131 ara\u015ft\u0131r\u0131ld\u0131. Tablo 5\u2019te bakterilerin M\u0130K de\u011ferlerinin da\u011f\u0131l\u0131m\u0131 verilmi\u015ftir.\u00a0<\/span><\/p>\n

KDE ta\u015f\u0131y\u0131c\u0131l\u0131\u011f\u0131 saptanm\u0131\u015f hastalardan izole edilmi\u015f KDE\u2019lerin 36 (%77)\u2019s\u0131nda MHT pozitif, 10 (%23)\u2019unda ise negatif sonu\u00e7 verdi. S\u00f6z konusu 46 hastan\u0131n 42 (%91.3)\u2019sinin su\u015flar\u0131na ise CARBA NP testi yap\u0131ld\u0131; 31 (%74) su\u015fta pozitif, 11 (%26) su\u015fta ise negatif sonu\u00e7 elde edildi<\/span>.\u00a0<\/span><\/p>\n

Temosilin M\u0130K de\u011feri sadece bir (%2) su\u015fta <32 g\/ml olup 10 su\u015fta imipenem\/EDTA ile imipenem M\u0130K de\u011ferinde 8 kattan fazla azalma oldu\u011fu g\u00f6r\u00fcld\u00fc.\u00a0<\/span><\/p>\n

Rektal S\u00fcr\u00fcnt\u00fcde \u00dcreyen KDE Su\u015flar\u0131n\u0131n Antibiyogramlar\u0131\u00a0<\/span><\/h3>\n
\"\"<\/a>

Tablo 6.<\/strong> Rektal S\u00fcr\u00fcnt\u00fc \u00d6rneklerinde \u00dcreyen Karbapeneme Diren\u00e7li Enterobacteriaceae<\/i> Su\u015flar\u0131n\u0131n Antibiyogram Sonu\u00e7lar\u0131<\/p><\/div>\n

Rektal s\u00fcr\u00fcnt\u00fc \u00f6rneklerinden izole edilmi\u015f 46 KDE su\u015funun 42\u2019sine disk dif\u00fczyon y\u00f6ntemiyle antimikrobiyal duyarl\u0131l\u0131k testi yap\u0131ld\u0131 (Tablo 6).<\/p>\n

\u00dcreyen su\u015flar\u0131n t\u00fcm\u00fc; ampisiline, amoksisilin\/klavulanata, sefuroksime, sefoksitine, seftriaksona, sefepime, piperasilin\/tazobaktama ve sefoperazon\/sulbaktama diren\u00e7liydi. Su\u015flar\u0131n %2\u2019si ampisilin-sulbaktam, seftazidim, meropenem, imipenem ve siprofloksasine; %5\u2019i aztreonama; %7\u2019si nitrofurantoin, kotrimaksazol, ofloksasin ve norfloksasine; %30\u2019u gentamisine; %36\u2019s\u0131 netilmisine; %40\u2019\u0131 amikasine; %69\u2019u fosfomisine ve %90\u2019\u0131 kolistine duyarl\u0131yd\u0131.\u00a0<\/span><\/p>\n

\u0130RDELEME<\/h2>\n

\u00c7al\u0131\u015fmam\u0131zda rektal KDE kolonizasyonunun belirlenmesi amac\u0131yla kullan\u0131lan \u00fc\u00e7 y\u00f6ntemden, en k\u0131sa s\u00fcrede sonu\u00e7lanan ve performans\u0131 en y\u00fcksek olan CromID CARBA idi. Bu y\u00f6ntemle, \u00f6rnek al\u0131nd\u0131ktan itibaren ilk 24. saatte rektal KDE varl\u0131\u011f\u0131 %91 duyarl\u0131l\u0131k ve %98\u2019lik \u00f6zg\u00fcll\u00fckle saptanabildi. Performans ve s\u00fcre a\u00e7\u0131s\u0131ndan direkt MacConkey y\u00f6ntemi ikinci s\u0131rada yer ald\u0131. Bu y\u00f6ntemle ilk 24. saatte rektal KDE varl\u0131\u011f\u0131 %87 duyarl\u0131l\u0131k, %80 \u00f6zg\u00fcll\u00fck ile saptand\u0131. Klasik CDC y\u00f6nteminin ise ilk 24. saatte, buyyondaki bulan\u0131kl\u0131\u011f\u0131n KDE varl\u0131\u011f\u0131n\u0131 g\u00f6sterdi\u011fi d\u00fc\u015f\u00fcn\u00fclerek yap\u0131lan de\u011ferlendirmesinde duyarl\u0131l\u0131\u011f\u0131 %78, \u00f6zg\u00fcll\u00fc\u011f\u00fc ise %42 olarak belirlendi.\u00a0 <\/span>\u0130lerleyen saatlerde (48-72 saat) KDE\u2019lerin tan\u0131mlanmas\u0131nda ek y\u00f6ntemlerin kullan\u0131lmas\u0131yla testlerin duyarl\u0131l\u0131klar\u0131 ayn\u0131 kalm\u0131\u015f, ancak \u00f6zg\u00fcll\u00fckleri artm\u0131\u015ft\u0131r.\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131zda klasik CDC y\u00f6nteminin duyarl\u0131l\u0131\u011f\u0131n\u0131n ve \u00f6zg\u00fcll\u00fc\u011f\u00fcn\u00fcn d\u00fc\u015f\u00fck olmas\u0131n\u0131n nedeni, hastalar\u0131m\u0131zda, KDE\u2019ye ek olarak, karbapenemlere, \u00f6zellikle ertapeneme diren\u00e7li di\u011fer bakterilerin [P. aeruginosa<\/i>, A. baumannii<\/i>, vankomisin diren\u00e7li enterokok (VDR) veya metisilin diren\u00e7li Staphylococcus aureus<\/i> (MRSA) gibi] de kolonizan olarak bulunmas\u0131 olabilir. Ger\u00e7ekten de \u00e7al\u0131\u015fmam\u0131zdaki hastalar\u0131n %18\u2019inin rektal s\u00fcr\u00fcnt\u00fc \u00f6rneklerinde bu bakteriler saptand\u0131. S\u00f6z konusu bakterilerin ertapenem i\u00e7eren buyyonda a\u015f\u0131r\u0131 \u00e7o\u011falmas\u0131, KDE\u2019lerin \u00fcremesinin inhibe olmas\u0131na yol a\u00e7m\u0131\u015f olabilir. Rektal s\u00fcr\u00fcnt\u00fc \u00f6rneklerinde KDE ara\u015ft\u0131ran bir di\u011fer \u00e7al\u0131\u015fmada da klasik CDC y\u00f6nteminin karbapenemaz \u00fcreten mikroorganizmalar\u0131n saptanmas\u0131ndaki duyarl\u0131l\u0131\u011f\u0131 %40, \u00f6zg\u00fcll\u00fc\u011f\u00fc ise %88 olarak saptanm\u0131\u015f olup yalanc\u0131 negatif sonu\u00e7lanan \u00f6rneklerin t\u00fcm\u00fcnde meropeneme duyarl\u0131 P. aeruginosa<\/i> izole edilmi\u015ftir.\u00a0 <\/span>Ayn\u0131 \u00e7al\u0131\u015fmada, bizim de kulland\u0131\u011f\u0131m\u0131z di\u011fer 2 y\u00f6ntem i\u00e7in belirlenmi\u015f duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fck de\u011ferleri direkt McConkey y\u00f6ntemi i\u00e7in %80 ve %85, ChromID CARBA y\u00f6ntemi i\u00e7in ise %100 ve %90\u2019d\u0131r; bu sonu\u00e7lar bizim \u00e7al\u0131\u015fmam\u0131zla uyumludur (10).\u00a0 <\/span>ChromID CARBA y\u00f6nteminin rektal \u00f6rneklerde KDE saptanmas\u0131nda y\u00fcksek performans g\u00f6sterebildi\u011fini bildiren ba\u015fka \u00e7al\u0131\u015fmalar da vard\u0131r (11, 21, 23). Bu y\u00f6ntemin duyarl\u0131 ve \u00f6zg\u00fcl olmas\u0131 yan\u0131nda, ilk 24. saatte KDE t\u00fcr\u00fcn\u00fc de tan\u0131mlayabilmesi bir di\u011fer avantaj\u0131d\u0131r (11). Ayr\u0131ca, kromojenik agar\u0131n maliyeti, kullan\u0131lan di\u011fer y\u00f6ntemlerdeki besiyerlerinin maliyetinden y\u00fcksek olmakla birlikte, bakterilerin tan\u0131mlanmas\u0131 i\u00e7in yap\u0131lan ek testlerin maliyetiyle birlikte de\u011ferlendirildi\u011finde ortaya \u00e7\u0131kan maliyetlerin birbirine yak\u0131n oldu\u011fu g\u00f6r\u00fclm\u00fc\u015ft\u00fcr. Olduk\u00e7a kolay uygulanabilen bir y\u00f6ntem olan direkt MacConkey y\u00f6ntemi, duyarl\u0131l\u0131\u011f\u0131n\u0131n klasik CDC\u2019den daha iyi olmas\u0131 ve 24. saatte g\u00fcvenilir sonu\u00e7 verebilmesi nedeniyle \u00f6zellikle kaynaklar\u0131n az, i\u015f y\u00fck\u00fcn\u00fcn fazla oldu\u011fu merkezlerde rutin olarak kullan\u0131labilir.<\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131zda KDE ta\u015f\u0131y\u0131c\u0131l\u0131\u011f\u0131 belirlenmi\u015f hastalardan izole edilmi\u015f su\u015flarda karbapenemaz varl\u0131\u011f\u0131n\u0131 g\u00f6stermek amac\u0131yla MHT ve CARBA NP testleri de yap\u0131lm\u0131\u015ft\u0131r. Su\u015flar\u0131n MHT\u2019de\u00a0 <\/span>%77\u2019si, CARBA NP testinde ise %74\u2019\u00fc pozitif olarak belirlenmi\u015f, her iki testin de performans\u0131n\u0131n yetersiz oldu\u011fu d\u00fc\u015f\u00fcn\u00fclm\u00fc\u015ft\u00fcr. Daha \u00f6nce yap\u0131lm\u0131\u015f \u00e7al\u0131\u015fmalarda hem MHT\u2019nin, hem de CARBA NP testinin karbapenemaz varl\u0131\u011f\u0131n\u0131 saptamada olduk\u00e7a duyarl\u0131 oldu\u011fu bildirilmekle birlikte, MHT\u2019nin \u00f6zellikle New Delhi metallo-\u00df-laktamaz (NDM) \u00fcreten su\u015flarda, CARBA NP testinin ise OXA-48 \u00fcreten su\u015flarda performanslar\u0131n\u0131n d\u00fc\u015f\u00fck oldu\u011fu bilinmektedir (16). \u00c7al\u0131\u015fmam\u0131zda molek\u00fcler y\u00f6ntemler kullan\u0131lmad\u0131\u011f\u0131 i\u00e7in KDE\u2019lerde hangi t\u00fcr karbapenemazlar\u0131n bulundu\u011fu bilinmemekle birlikte yine merkezimizde ve ayn\u0131 YB\u00dc\u2019lerde bir y\u0131l \u00f6nce yap\u0131lm\u0131\u015f bir tez \u00e7al\u0131\u015fmas\u0131nda hastalardan izole edilmi\u015f KDE su\u015flar\u0131n\u0131n \u00e7o\u011funda OXA-48, yakla\u015f\u0131k %10\u2019unda da bla<\/i>NDM<\/sub> saptanm\u0131\u015ft\u0131r (13). Bu veriler, \u00e7al\u0131\u015fmam\u0131zda MHT ve CARBA NP testlerinin pozitiflik oranlar\u0131n\u0131n %70\u2019lerde olmas\u0131n\u0131 a\u00e7\u0131klayabilir. Ancak eldeki su\u015flar\u0131n molek\u00fcler incelemesini yapmadan kesin bir sonuca varmak m\u00fcmk\u00fcn de\u011fildir. \u00a0 <\/span>CARBA NP testiyle ilgili bir di\u011fer konu ise bu testin sonucunun, \u00e7al\u0131\u015f\u0131lacak \u00f6rne\u011fin \u00fcretildi\u011fi k\u00fclt\u00fcr ortam\u0131ndan etkilenmesidir; CARBA NP testinden en do\u011fru sonu\u00e7lar\u0131n al\u0131nabilmesi i\u00e7in, kanl\u0131 agarda \u00fcretilmi\u015f kolonilerin kullan\u0131lmas\u0131 \u00f6nerilmektedir (6). \u00c7al\u0131\u015fmam\u0131zda, MacConkey agarda \u00fcretilmi\u015f su\u015flarla \u00e7al\u0131\u015f\u0131lmas\u0131 da sonu\u00e7lar\u0131 etkilemi\u015f olabilir. Ancak su\u015flar\u0131n kanl\u0131 agarda tekrar \u00fcretilmesi de ek maliyet ve zaman kayb\u0131na yol a\u00e7aca\u011f\u0131 i\u00e7in bu testin rutinde kullan\u0131m\u0131 bak\u0131m\u0131ndan sorun yaratabilir.\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131zda, KDE olan su\u015flarda karbapenemaz t\u00fcr\u00fcn\u00fc tahmin etmede kullan\u0131labilecek fenotipik y\u00f6ntemlerden, MBL i\u00e7in olan aztreonam duyarl\u0131l\u0131\u011f\u0131, EDTA ile inhibisyon testi ve OXA-48\u2019ler i\u00e7in olan temosilin direnci testi de yap\u0131lm\u0131\u015ft\u0131r. Aztreonam MBL\u2019lere diren\u00e7li, KPC \u03b2-laktamazlara ise duyarl\u0131 olup (3) bu \u00f6zelli\u011fiyle MBL varl\u0131\u011f\u0131n\u0131 tahmin etmede kullan\u0131labilir. \u00c7al\u0131\u015fmam\u0131zda izole edilen KDE su\u015flar\u0131n\u0131n ikisi\u00a0 <\/span>(%4.7) aztreonama duyarl\u0131yd\u0131. Karbapenemaz t\u00fcr\u00fcn\u00fc tahmin etmede kullan\u0131labilen bir di\u011fer y\u00f6ntem olan imipenem-EDTA\u00a0 <\/span>inhibisyon testiyle, toplam 10 (%20) su\u015fta, imipenem M\u0130K de\u011ferlerinde 8 kattan fazla d\u00fc\u015fme oldu\u011fu g\u00f6r\u00fclerek, bu su\u015flar\u0131n MBL \u00fcretiyor olabilece\u011fi d\u00fc\u015f\u00fcn\u00fcld\u00fc. Hastanemizde daha \u00f6nceki molek\u00fcler \u00e7al\u0131\u015fmalarda bla<\/i>NDM<\/sub> varl\u0131\u011f\u0131 g\u00f6sterilmi\u015f oldu\u011fu i\u00e7in, aztreonam duyarl\u0131l\u0131\u011f\u0131 veya EDTA ile M\u0130K azalmas\u0131 olan su\u015flarda bu enzimin var olmas\u0131 muhtemeldir (13). \u00dclkemizdeki di\u011fer hastanelerde de son y\u0131llarda gittik\u00e7e artan oranlarda NDM bildirilmesi nedeniyle de bu konu ayr\u0131ca \u00f6nemlidir (16, 17, 13).\u00a0 <\/span>\u00c7al\u0131\u015fmam\u0131zdan izole edilen su\u015flardan biri hari\u00e7 t\u00fcm\u00fcnde temosilin M\u0130K\u2019in >32 \u03bcg\/ml olmas\u0131 hem \u00fclkemizde hem de hastanemizde endemik oldu\u011fu bilinen OXA-48 t\u00fcr\u00fc karbapenemazlar\u0131n varl\u0131\u011f\u0131yla uyumludur (18, 16, 17, 13). Molek\u00fcler y\u00f6ntemlerin hem maliyet hem de uygulama zorlu\u011fu nedeniyle rutinde kullan\u0131lamad\u0131\u011f\u0131 durumlarda, bu t\u00fcr basit fenotipik y\u00f6ntemlerle karbapenemaz t\u00fcrlerinin takip edilebilece\u011fi ve gere\u011finde molek\u00fcler y\u00f6ntemlerin kullan\u0131labilece\u011fi d\u00fc\u015f\u00fcn\u00fcld\u00fc.\u00a0<\/span><\/p>\n

Rektal KDE su\u015flar\u0131n\u0131n duyarl\u0131l\u0131k \u00f6zellikleri incelendi\u011finde, kolistinin halen en duyarl\u0131 ajan oldu\u011fu ancak su\u015flar\u0131n %9.6\u2019s\u0131n\u0131n kolistine diren\u00e7li oldu\u011fu g\u00f6r\u00fcld\u00fc. Kara\u00e7i\u2019de yap\u0131lan bir \u00e7al\u0131\u015fmada kolistine diren\u00e7 oran\u0131 %15.9 olarak (14); Yunanistan\u2019da yap\u0131lan bir \u00e7al\u0131\u015fmada ise kolistine diren\u00e7 oranlar\u0131 %10.5-20 aras\u0131nda bildirilmi\u015ftir (19, 20). Yunanistan, d\u00fcnyada en y\u00fcksek kolistin diren\u00e7 oranlar\u0131 bildiren \u00fclkededir (15). KDE\u2019lerdeki kolistin direncinin bu seviyelere \u00e7\u0131kmas\u0131, bu bakterilerle infekte hastalar\u0131n zaten olduk\u00e7a s\u0131n\u0131rl\u0131 olan tedavi se\u00e7eneklerinin daha da azalmas\u0131 bak\u0131m\u0131ndan \u00e7ok \u00f6nemlidir ve yak\u0131ndan izlenmelidir.<\/p>\n

\u00c7al\u0131\u015fmam\u0131z, prospektif kohort olarak planlanm\u0131\u015f bir \u00e7al\u0131\u015fma olmas\u0131n\u0131n yan\u0131 s\u0131ra \u00f6zellikle kaynaklar\u0131n ve insan g\u00fcc\u00fcn\u00fcn s\u0131n\u0131rl\u0131 oldu\u011fu yerler i\u00e7in bir \u00e7\u00f6z\u00fcm \u00fcretmek amac\u0131yla tasarlanm\u0131\u015f olmas\u0131 g\u00fc\u00e7l\u00fc y\u00f6n\u00fcd\u00fcr. \u0130zole edilen KDE su\u015flar\u0131nda molek\u00fcler y\u00f6ntemlerle karbapenemaz t\u00fcrlerinin ara\u015ft\u0131r\u0131lamam\u0131\u015f olmas\u0131 ise \u00e7al\u0131\u015fmam\u0131z\u0131n en \u00f6nemli eksi\u011fidir.<\/p>\n

Sonu\u00e7 olarak, rektal KDE ta\u015f\u0131y\u0131c\u0131l\u0131\u011f\u0131n\u0131n belirlenmesinde ChromID CARBA y\u00f6nteminin\u00a0 <\/span>performans\u0131, klasik CDC ve direkt MacConkey y\u00f6nteminden daha iyi olmakla birlikte, \u00f6zellikle kaynak sorunu olan yerlerde direkt MacConkey y\u00f6nteminin de kullan\u0131labilece\u011fi g\u00f6r\u00fcld\u00fc. Su\u015flardaki karbapenemaz varl\u0131\u011f\u0131n\u0131 g\u00f6stermek bak\u0131m\u0131ndan, CARBA NP testinin, MHT\u2019ye \u00fcst\u00fcnl\u00fc\u011f\u00fc olmad\u0131\u011f\u0131 g\u00f6r\u00fcld\u00fc.\u00a0 <\/span>KDE olarak tan\u0131mlanm\u0131\u015f bakterilerin yakla\u015f\u0131k %20\u2019sinde, aztreonam duyarl\u0131l\u0131\u011f\u0131 veya EDTA inhibisyonu y\u00f6ntemiyle MBL\u2019lerin olabilece\u011fi tahmin edildi. \u00dclkemizde MBL\u2019lerin gittik\u00e7e artan oranlarda bildirilmesi nedeniyle, molek\u00fcler y\u00f6ntemlere ula\u015fman\u0131n her zaman m\u00fcmk\u00fcn olmad\u0131\u011f\u0131 merkezlerde\u00a0 <\/span>KDE\u2019lerde aztreonam duyarl\u0131l\u0131\u011f\u0131 ve\u00a0 <\/span>EDTA inhibisyon y\u00f6nteminin birlikte kullan\u0131m\u0131yla bu t\u00fcr karbapenemazlar\u0131n varl\u0131\u011f\u0131n\u0131n tahmin edilebilece\u011fi ve gere\u011finde\u00a0 <\/span>molek\u00fcler y\u00f6ntemlerin kullan\u0131labilece\u011fi d\u00fc\u015f\u00fcn\u00fclm\u00fc\u015ft\u00fcr. \u00a0 \u00a0 \u00a0 \u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e Son y\u0131llarda \u00fclkemizde gittik\u00e7e artan s\u0131kl\u0131kta g\u00f6r\u00fclmekte olan karbapeneme diren\u00e7li Enterobacteriaceae (KDE) infeksiyonlar\u0131, daha \u00e7ok komorbiditeleri olan ve yo\u011fun sa\u011fl\u0131k bak\u0131m\u0131 uygulanan hastalarda ortaya \u00e7\u0131kmaktad\u0131r. KDE\u2019ler, ciddi infeksiyonlara neden olarak hem y\u00fcksek mortalite ve morbiditeye yol a\u00e7makta hem de hastanede yat\u0131\u015f s\u00fcresini uzatarak maliyetleri \u00f6nemli \u00f6l\u00e7\u00fcde art\u0131rmaktad\u0131r (1). Gram-negatif \u00e7omaklarda karbapenem direnci \u015fu mekanizmalar\u0131n […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[3948,4387,5492],"class_list":["post-25277","post","type-post","status-publish","format-standard","hentry","category-ozgun-arastirma","tag-karbapenem","tag-karbapenemaz","tag-rektal-kolonizasyon"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25277","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=25277"}],"version-history":[{"count":4,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25277\/revisions"}],"predecessor-version":[{"id":25825,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25277\/revisions\/25825"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=25277"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=25277"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=25277"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}