{"id":25437,"date":"2022-09-28T09:00:10","date_gmt":"2022-09-28T06:00:10","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=25437"},"modified":"2022-12-26T18:21:50","modified_gmt":"2022-12-26T15:21:50","slug":"acinetobacter-icin-kolistin-direnci","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2022\/09\/28\/acinetobacter-icin-kolistin-direnci\/","title":{"rendered":"Klinik \u00d6rneklerden \u0130zole Edilen \u00c7oklu Diren\u00e7li Acinetobacter baumannii <\/i>\u0130zolatlar\u0131n\u0131n Kolistin Direncinin S\u0131v\u0131 Mikrodil\u00fcsyon, Sensititre ve \u0130ki Farkl\u0131 Otomatize Sistem ile Kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131"},"content":{"rendered":"

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

Acinetobacter baumannii<\/i>, \u00f6zellikle yo\u011fun bak\u0131m \u00fcnitelerinde artan morbidite ve mortalite ile ili\u015fkili ciddi hastane infeksiyonlar\u0131ndan giderek daha fazla sorumlu tutulmaktad\u0131r. Kolistin, ilk olarak 1949\u2019da Paenibacillus polymyxa<\/i>\u2019dan izole edilmi\u015f olup A\u2019dan E\u2019ye kadar be\u015f farkl\u0131 yap\u0131sal analo\u011fa sahiptir; polimiksin B ve E (kolistin) klinik kullan\u0131mda olanlard\u0131r. Bir ekzosiklik zincir, bir heptapeptit halkas\u0131 ve pozitif y\u00fckl\u00fc bir ya\u011f asidi kuyru\u011fu ile Gram-negatif lipopolisakkarit membran\u0131 ile etkile\u015fime giren katyonik bir polipeptittir. Nefrotoksik, n\u00f6rotoksik etkileri ve doz optimizasyonundaki s\u0131k\u0131nt\u0131lar nedeniyle 1959\u2019da klinik kullan\u0131ma girmi\u015f olsa da 1980\u2019lerde kullan\u0131m\u0131 s\u0131n\u0131rland\u0131r\u0131lm\u0131\u015ft\u0131r. Kolistin s\u00fclfat\u0131n intraven\u00f6z formunun baz\u0131 \u00e7al\u0131\u015fmalarda daha g\u00fcvenilir oldu\u011funun g\u00f6sterilmesinin ard\u0131ndan Gram-negatif bakterilerin neden oldu\u011fu \u00e7oklu ilaca diren\u00e7li infeksiyonlarda kullan\u0131lmas\u0131 tekrar g\u00fcndeme gelmi\u015ftir. Kolistinin geni\u015f spektrumlu olmas\u0131, bakterisidal etkisinin h\u0131zl\u0131 olmas\u0131 ve yeni geli\u015ftirilen antibiyotiklerin say\u0131s\u0131n\u0131n yetersiz olmas\u0131 gibi nedenlerden dolay\u0131 klinisyenler taraf\u0131ndan 1990\u2019lardan itibaren yeniden kullan\u0131lmaya ba\u015flanm\u0131\u015ft\u0131r (1, 2).<\/p>\n

Enterobacteriaceae<\/i>, Pseudomonas aeruginosa<\/i> ve Acinetobacter<\/i> spp.\u2019de kolistin duyarl\u0131l\u0131\u011f\u0131n\u0131n tespiti i\u00e7in Klinik ve Laboratuvar Standartlar\u0131 Enstit\u00fcs\u00fc (\u201cClinical and Laboratory Standards Institute – CLSI\u201d) ve Avrupa Antimikrobiyal Duyarl\u0131l\u0131k Testi Komitesi (\u201cEuropean Committee on Antimicrobial Susceptibility Testing – EUCAST\u201d)\u00a0 <\/span>ortak \u00e7al\u0131\u015fma grubu ISO standard\u0131 20776-1\u2019e g\u00f6re polisorbat-80 gibi y\u00fczey aktif maddeler eklenmeden kolistinin s\u00fclfat tuzunu kullanarak polistiren mikrotitre plaklar\u0131 ile s\u0131v\u0131 mikrodil\u00fcsyon (SMD) \u00e7al\u0131\u015f\u0131lmas\u0131n\u0131 referans y\u00f6ntem olarak belirlemi\u015ftir (3). Ancak SMD plaklar\u0131n\u0131n haz\u0131rlanmas\u0131 son derecede yo\u011fun emek ve zaman gerektirdi\u011finden, \u00e7o\u011fu rutin laboratuvar referans metodu uygulayamamaktad\u0131r. Bu nedenle son y\u0131llarda ticari birka\u00e7 s\u0131v\u0131 mikrodil\u00fcsyon y\u00f6ntemi kullan\u0131ma sunulmu\u015ftur. EUCAST, kolistin direncinin tespitinde gradyan testleri ve yar\u0131 otomatize sistemlerin kullan\u0131lmamas\u0131n\u0131 \u00f6nermekte ve konu ile ilgili uyar\u0131lar\u0131n\u0131 s\u00fcrekli g\u00fcncellemektedir (4).\u00a0<\/span><\/p>\n

Kullan\u0131lan otomatize sistemlerden BD Phoenix<\/span>\u2122<\/sup><\/span> 100 sisteminde (Becton Dickinson, ABD), 85 adet kuyucuk ve bu kuyucuklarda kuru toz halinde antibiyotikler bulunmaktad\u0131r. Test, s\u0131v\u0131 bazl\u0131 mikrodil\u00fcsyon prensibiyle \u00e7al\u0131\u015fmaktad\u0131r. MicroScan WalkAway<\/span>\u2122 <\/sup><\/span>sistemi (Beckman Coulter, ABD) mikrodil\u00fcsyonun yar\u0131 otomatize edilmi\u015f halidir. S\u0131v\u0131 mikrodil\u00fcsyon y\u00f6ntemlerinden biri olan Sensititre\u2122 mikrodil\u00fcsyon y\u00f6nteminde (Thermo Fisher Scientific, ABD) ise mikroplaklar\u0131n kuyucuklar\u0131nda liyofilize halde kolistinin daha \u00f6nce seyreltilmi\u015f konsantrasyonlar\u0131 (0.125-128 \u03bcg\/ml) bulunmaktad\u0131r (5).\u00a0<\/span><\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131zda, A. baumannii<\/i> izolatlar\u0131nda saptanan kolistin duyarl\u0131l\u0131klar\u0131n\u0131n kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131 ama\u00e7land\u0131 ve kolistin direncinin belirlenmesinde alt\u0131n standart y\u00f6ntem olan SMD y\u00f6nteminin yan\u0131 s\u0131ra, ticari bir s\u0131v\u0131 mikrodil\u00fcsyon y\u00f6ntemi olan Sensititre\u2122<\/sup><\/span> mikrodil\u00fcsyon y\u00f6ntemi, BD Phoenix\u2122<\/sup><\/span> 100 ve MicroScan WalkAway\u2122<\/sup><\/span> otomatize sistemleri kullan\u0131ld\u0131. \u00a0<\/span><\/p>\n

Y\u00d6NTEMLER<\/h2>\n

\u00c7al\u0131\u015fmam\u0131zda, \u00e7oklu antibiyotik diren\u00e7li 100 adet A. baumannii<\/i> su\u015fu kolistin duyarl\u0131l\u0131\u011f\u0131 y\u00f6n\u00fcnden incelemeye al\u0131nd\u0131. Laboratuvar\u0131m\u0131za gelen \u00e7e\u015fitli klinik \u00f6rnekler %5 kanl\u0131 agar ve \u201cEosin methylene blue\u201d (EMB) agara ekilerek 37\u00b0C\u2019de 18-24 saat ink\u00fcbe edildi. K\u00fclt\u00fcrde \u00fcreyen bakterilerin t\u00fcr d\u00fczeyinde tan\u0131mlanmas\u0131, BD Phoenix\u2122<\/sup><\/span> 100 ve MicroScan WalkAway\u2122<\/sup><\/span> otomatize sistemleri kullan\u0131larak yap\u0131ld\u0131. \u0130zolatlar, \u00e7al\u0131\u015fmaya al\u0131n\u0131ncaya kadar %15 gliserol i\u00e7eren Mueller-Hinton buyyon saklama besiyerlerinde -80\u00b0C\u2019de sakland\u0131. \u00c7al\u0131\u015fma \u00f6ncesinde derin dondurucudan \u00e7\u0131kar\u0131lan izolatlar\u0131 canland\u0131rmak i\u00e7in %5 koyun kanl\u0131 agara ekim yap\u0131ld\u0131 ve besiyerleri 35\u00b0C\u2019de 18-24 saat ink\u00fcbe edildi. \u00dcreyen izolatlardan tekrar pasajlar al\u0131narak saf k\u00fclt\u00fcr halinde elde edilmeleri sa\u011fland\u0131. Olas\u0131 salg\u0131n su\u015flar\u0131n\u0131n d\u0131\u015flanmas\u0131 amac\u0131yla molek\u00fcler y\u00f6ntemlerle bir \u00e7al\u0131\u015fma yap\u0131lmad\u0131. Her hastadan sadece bir izolat \u00e7al\u0131\u015fmaya dahil edildi. Toplam 100 adet A. baumannii<\/i> izolat\u0131n\u0131n kolistin duyarl\u0131l\u0131klar\u0131; s\u0131v\u0131 mikrodil\u00fcsyon ve Sensititre\u2122<\/sup><\/span> mikrodil\u00fcsyon y\u00f6ntemleri, BD Phoenix\u2122<\/sup><\/span> 100 ve MicroScan WalkAway\u2122<\/sup><\/span> otomatize sistemleri kullan\u0131larak kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131.\u00a0<\/span><\/p>\n

BD Phoenix\u2122 100 ve MicroScan WalkAway\u2122 <\/i>Otomotize Sistemleri<\/h3>\n

Bakteri s\u00fcspansiyonunun bulan\u0131kl\u0131\u011f\u0131 0.5-0.6 McFarland olacak \u015fekilde haz\u0131rland\u0131. BD Phoenix\u2122 100 analizleri i\u00e7in 1-4 mg\/lt kolistin konsantrasyonlar\u0131n\u0131 test eden ADT paneli ve ID kartlar\u0131 kullan\u0131ld\u0131. MicroScan WalkAway\u2122<\/sup><\/span> analizleri i\u00e7in ise 2-4 mg\/lt kolistin konsantrasyonlar\u0131n\u0131 test eden ADT paneli ve ID kartlar\u0131 kullan\u0131ld\u0131. Sonu\u00e7lar, 18-24 saatlik ink\u00fcbasyondan sonra cihaz\u0131n \u00e7al\u0131\u015fma men\u00fcs\u00fcnden de\u011ferlendirildi. \u0130ki sistemde de EUCAST versiyon 11.0 \u00f6nerileri do\u011frultusunda; minimum inhibit\u00f6r konsantrasyonu (M\u0130K) de\u011feri \u2264 2 mg\/lt olan izolatlar duyarl\u0131, >2 mg\/lt olan izolatlar diren\u00e7li olarak de\u011ferlendirildi (3).<\/p>\n

Sensititre\u2122 Mikrodil\u00fcsyon Y\u00f6ntemi\u00a0<\/span><\/h3>\n

Mikrodil\u00fcsyon temeline dayanan, 0.125-128 mg\/lt konsantrasyon aral\u0131\u011f\u0131nda dehidrate kolistin ve \u00fcreme kontrol kuyucu\u011fu i\u00e7eren mikroplaklar halinde kullan\u0131ma haz\u0131r bir y\u00f6ntemdir. Bakteri s\u00fcspansiyonu, taze k\u00fclt\u00fcrden steril distile su i\u00e7erisinde 0.5 McFarland bulan\u0131kl\u0131\u011f\u0131nda olacak \u015fekilde haz\u0131rland\u0131ktan sonra, bu \u00e7\u00f6zeltiden 10 \u00b5l al\u0131narak 11 ml Mueller-Hinton buyyon i\u00e7eren t\u00fcpe eklendi; buradan 50 \u00b5l al\u0131narak, 0.125-128 mg\/lt kolistin i\u00e7eren haz\u0131r mikroplaklara inok\u00fcle edildi.<\/p>\n

S\u0131v\u0131 Mikrodil\u00fcsyon Y\u00f6ntemi<\/h3>\n

\u00dcreticinin \u00f6nerileri do\u011frultusunda; aktif madde olarak kolistin s\u00fclfat (Sigma Aldrich, ABD) s\u00fcspansiyon haline getirilerek 256 \u03bcg\/ml\u2019lik stok sol\u00fcsyon haz\u0131rland\u0131. Stok sol\u00fcsyon kullan\u0131larak, mikrodil\u00fcsyon plaklar\u0131ndaki Mueller-Hinton buyyonunda seri dil\u00fcsyonlar (0.125-128\u03bcg\/ml) yap\u0131ld\u0131. T\u00fcm izolatlardan 0.5 McFarland standard\u0131 bulan\u0131kl\u0131\u011f\u0131nda s\u00fcspansiyon haz\u0131rland\u0131ktan sonra son bakteri konsantrasyonu 5\u00d7105 <\/sup>cfu\/ml olacak \u015fekilde mikrodil\u00fcsyon plaklar\u0131na eklendi.\u00a0<\/span><\/p>\n

Sensititre\u2122<\/sup><\/span> sisteminde ve s\u0131v\u0131 mikrodil\u00fcsyon y\u00f6nteminde, mikroplaklar 18-20 saat boyunca 35\u00b0C\u2019de ink\u00fcbe edildi. \u00c7al\u0131\u015fmam\u0131z, ayn\u0131 g\u00fcn i\u00e7inde ayn\u0131 ekip taraf\u0131ndan ger\u00e7ekle\u015ftirildi. \u0130nk\u00fcbasyon sonras\u0131nda sonu\u00e7lar, birbirinden ba\u011f\u0131ms\u0131z \u00e7ift g\u00f6z kontroll\u00fc olarak de\u011ferlendirildi. \u00dcremenin olmad\u0131\u011f\u0131 en d\u00fc\u015f\u00fck kolistin konsantrasyonu, M\u0130K de\u011feri olarak tespit edildi. Kalite kontrol\u00fc, kolistin duyarl\u0131 ATCC 25922 Escherichia coli<\/i> ve kolistin diren\u00e7li NCTC 13846 (mcr-1 pozitif) E. coli<\/i> su\u015flar\u0131 ile ger\u00e7ekle\u015ftirildi. EUCAST versiyon 11.0 \u00f6nerileri do\u011frultusunda M\u0130K de\u011feri \u2264 2 mg\/lt olan izolatlar duyarl\u0131, >2 mg\/lt olan izolatlar diren\u00e7li olarak de\u011ferlendirildi (3).<\/p>\n

\u0130statistiksel Analiz<\/h3>\n

Veriler, SPSS (\u201cStatistical Package for Social Sciences\u201d) versiyon 22.0 program\u0131 (IBM Corp., ABD) ile de\u011ferlendirildi. \u00c7al\u0131\u015fmada tan\u0131mlay\u0131c\u0131 veriler kategorik verilerde n ve % de\u011ferleri; s\u00fcrekli verilerde ise ortalama\u00b1standart sapma de\u011ferleri ile g\u00f6sterildi. Gruplar aras\u0131 kategorik de\u011fi\u015fkenlerin kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131nda \u03c7\u00b2 analizi uyguland\u0131. S\u00fcrekli de\u011fi\u015fkenlerin normal da\u011f\u0131l\u0131ma uygunlu\u011fu Kolmogorov-Smirnov testi ile de\u011ferlendirildi. Normal da\u011f\u0131l\u0131ma uyan de\u011fi\u015fkenlerin iki grup aras\u0131ndaki kar\u015f\u0131la\u015ft\u0131rmas\u0131nda Student t testi uyguland\u0131. Analizlerde istatistiksel anlaml\u0131l\u0131k d\u00fczeyi p<\/i><0.05 olarak kabul edildi.<\/p>\n

Duyarl\u0131l\u0131k testlerinin kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131nda \u201ckategorik uyum<\/i>\u201d (KU) oran\u0131 dikkate al\u0131nd\u0131. Kategorik uyum; test su\u015funun CLSI vb. kriterlere g\u00f6re yorumlanan duyarl\u0131l\u0131k sonu\u00e7lar\u0131n\u0131n (duyarl\u0131 ve diren\u00e7li) uyumu olarak tan\u0131mland\u0131. \u201cB\u00fcy\u00fck hata<\/i>\u201d (BH), bir antibiyotik duyarl\u0131l\u0131k testinin diren\u00e7li, referans testin duyarl\u0131 sonu\u00e7 vermesi; \u201c\u00e7ok b\u00fcy\u00fck hata<\/i>\u201d (\u00c7BH) ise bir antibiyotik duyarl\u0131l\u0131k testinin duyarl\u0131 sonu\u00e7 verirken referans testin diren\u00e7li sonu\u00e7 vermesi olarak tan\u0131mland\u0131 (6). Referans testi olan M\u0130K sonu\u00e7lar\u0131 ile MikroScan\u2122<\/sup><\/span>, BD Phoenix\u2122 100, Sensititre\u2122<\/sup><\/span> sonu\u00e7lar\u0131 kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131 ve KU, \u00c7BH ve BH oranlar\u0131 hesapland\u0131. Uluslararas\u0131 Standartlar Te\u015fkilat\u0131 (\u201cInternational Organization of Standardization \u2013 ISO\u201d) taraf\u0131ndan belirlenen kriterlere g\u00f6re kabul edilebilir performans; KU i\u00e7in \u2265%90; \u00c7BH ve BH i\u00e7in \u2264%3 olarak belirlendi (7).<\/p>\n

\u00c7al\u0131\u015fma i\u00e7in F\u0131rat \u00dcniversitesi Klinik Ara\u015ft\u0131rmalar Etik Kurulu\u2019ndan 28 Kas\u0131m 2019 tarih ve 13281952-514.10-E.1983 karar numaras\u0131yla onay al\u0131nd\u0131. \u00c7al\u0131\u015fma s\u00fcrecinde ara\u015ft\u0131rma ve yay\u0131n eti\u011fi ilkelerine uyuldu.\u00a0<\/span><\/p>\n

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

\u015eekil 1.<\/strong>A. baumannii\u2019<\/i>nin d\u00f6rt farkl\u0131 y\u00f6ntemden elde edilen kolistin duyarl\u0131l\u0131k sonu\u00e7lar\u0131.<\/p><\/div>\n

\"\"<\/a>

Tablo 1.<\/strong> Acinetobacter baumannii<\/i> \u0130zolatlar\u0131nda Kolistin Duyarl\u0131l\u0131k Oranlar\u0131n\u0131n Testlere G\u00f6re Kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131<\/p><\/div>\n

\"\"<\/a>

Tablo 2.<\/strong>\u0130zolatlar\u0131n SMD, BD Phoenix\u2122 100, MicroScan WalkAway\u2122 ve Sensititre\u2122 Y\u00f6ntemleri ile Kolistin M\u0130K Sonu\u00e7lar\u0131<\/p><\/div>\n

\u00c7al\u0131\u015fmaya \u00e7oklu ilaca diren\u00e7li 36\u2019s\u0131 trakeal aspirat, 34\u2019\u00fc balgam, 13\u2019\u00fc idrar, 10\u2019u kan ve 7\u2019si yara \u00f6rne\u011finden izole edilmi\u015f toplam 100 adet A. baumannii<\/i> su\u015fu dahil edildi. Su\u015flar\u0131n 70\u2019i kad\u0131n hastalardan, 30\u2019u ise erkek hastalardan al\u0131nan \u00f6rneklerden izole edildi. Hastalar\u0131n ya\u015f ortalamas\u0131 67.1\u00b117.4 (minimum=18-maksimum=93) idi.<\/p>\n

Kolistin i\u00e7in; SMD, MikroScan WalkAway\u2122<\/sup><\/span>, BD Phoenix\u2122<\/sup><\/span> 100 ve Sensititre\u2122<\/span> mikrodil\u00fcsyon y\u00f6ntemleri kullan\u0131larak 100 su\u015f i\u00e7in tespit edilen duyarl\u0131l\u0131k ve diren\u00e7lilik oranlar\u0131 \u015eekil 1\u2019de verilmi\u015ftir.\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fmaya dahil edilen Acinetobacter <\/i>spp. su\u015flar\u0131n\u0131n; SMD, MikroScan WalkAway\u2122<\/sup><\/span>, BD Phoenix\u2122<\/sup><\/span> 100 ve Sensititre\u2122<\/sup><\/span> ile saptanan kolistin duyarl\u0131l\u0131klar\u0131, su\u015flar\u0131n izole edildi\u011fi hastalar\u0131n cinsiyetleri ve ya\u015flar\u0131 a\u00e7\u0131s\u0131ndan de\u011ferlendirildi\u011finde anlaml\u0131 d\u00fczeyde bir farkl\u0131l\u0131k g\u00f6r\u00fclmedi (p<\/i>>0.05).\u00a0<\/span><\/p>\n

MikroScan WalkAway\u2122<\/sup><\/span>, BD Phoenix\u2122<\/sup><\/span> 100, Sensititre\u2122<\/sup><\/span> y\u00f6ntemleri ile elde edilen kolistin diren\u00e7 oranlar\u0131 alt\u0131n standart y\u00f6ntem olan SMD y\u00f6ntemi ile kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131. S\u0131v\u0131 mikrodil\u00fcsyon y\u00f6ntemi alt\u0131n standart kabul edildi\u011finde; MicroScan WalkAway\u2122<\/sup><\/span> sisteminin KU oran\u0131 %97, \u00c7BH oran\u0131 %2 ve BH oran\u0131 %1 olarak tespit edildi. Sensititre\u2122<\/sup><\/span> y\u00f6nteminin ise KU oran\u0131 %68, \u00c7BH oran\u0131 %5 ve BH oran\u0131 %27 olarak tespit edildi. Sensititre\u2122<\/sup><\/span> y\u00f6ntemine g\u00f6re yanl\u0131\u015f duyarl\u0131 sonu\u00e7 elde etti\u011fimiz be\u015f \u00f6rne\u011fin M\u0130K de\u011feri 2 \u00b5g\/ml olup SMD testinde bu \u00f6rneklerin M\u0130K de\u011feri 4 \u00b5g\/ml olarak tespit edildi.\u00a0 <\/span>Elde edilen verilere g\u00f6re MikroScan WalkAway\u2122<\/sup><\/span>, BD Phoenix\u2122<\/sup><\/span> 100 ve Sensititre\u2122<\/sup><\/span> y\u00f6ntemlerinin KU, BH ve \u00c7BH oranlar\u0131 Tablo 1\u2019de; izolatlar\u0131n SMD, BD Phoenix\u2122<\/sup><\/span> 100, MicroScan WalkAway\u2122<\/sup><\/span> ve Sensititre\u2122<\/sup><\/span> y\u00f6ntemleri ile elde edilen kolistin M\u0130K sonu\u00e7lar\u0131 Tablo 2\u2019de verilmi\u015ftir.<\/p>\n

\u0130RDELEME<\/h2>\n

Kolistin, karbapenemlere diren\u00e7li Gram-negatif bakteri infeksiyonlar\u0131n\u0131n tedavisinde yan etkilerine ra\u011fmen kullan\u0131lma s\u0131kl\u0131\u011f\u0131 artan antibiyotiklerden biridir (8). Polimiksinlerin b\u00fcy\u00fck molek\u00fcler boyutlar\u0131ndan dolay\u0131 agarda dif\u00fczyonlar\u0131n\u0131n zay\u0131f olmas\u0131, katyonik yap\u0131lar\u0131, ila\u00e7 tozu bile\u015fimine ili\u015fkin endi\u015feler ve hetero diren\u00e7lerinin bulunmas\u0131 nedeniyle duyarl\u0131l\u0131k testlerine ili\u015fkin zorluklarla kar\u015f\u0131la\u015f\u0131lmaktad\u0131r (9). Bununla birlikte kolistin duyarl\u0131l\u0131\u011f\u0131n\u0131n tespitinde \u00f6nerilen test y\u00f6ntemi olan SMD\u2019nin yo\u011fun emek, zaman ve tecr\u00fcbe gerektirmesinden dolay\u0131 rutin mikrobiyoloji laboratuvarlar\u0131n\u0131n i\u015f ak\u0131\u015f\u0131na kolayca uyarlanabilecek yeni bir tan\u0131 arac\u0131 bulma \u00e7abas\u0131 devam etmektedir (10).\u00a0<\/span><\/p>\n

Otomatize sistemler, klinik \u00f6rneklerden izole edilen mikroorganizmalar\u0131n tan\u0131mlanmas\u0131nda ve antibiyotik duyarl\u0131l\u0131\u011f\u0131n\u0131n saptamas\u0131nda \u00f6nemli bir role sahiptir. Kolistin duyarl\u0131l\u0131l\u0131\u011f\u0131n\u0131 test etmek i\u00e7in yap\u0131lan \u00e7al\u0131\u015fmalar genellikle VITEK\u00ae<\/sup> 2 (bioM\u00e9rieux, ABD) ile yap\u0131lm\u0131\u015f olup \u00e7al\u0131\u015fmam\u0131zda kulland\u0131\u011f\u0131m\u0131z Phoenix\u2122<\/sup><\/span> 100 ve MicroScan WalkAway\u2122<\/sup><\/span> otomatize sistemiyle kar\u015f\u0131la\u015ft\u0131rma \u00e7al\u0131\u015fmalar\u0131 daha azd\u0131r (11-15) .<\/p>\n

Vasoo (9) yapm\u0131\u015f oldu\u011fu \u00e7al\u0131\u015fmada, Sensititre\u2122<\/sup><\/span> mikrodil\u00fcsyon y\u00f6ntemi ile kolistin ve polimiksin B i\u00e7in %90 \u201ckategorik uyum<\/i>\u201d saptam\u0131\u015ft\u0131r. Yirmi iki adet Acinetobacter<\/i> spp. izolat\u0131n\u0131n kolistin duyarl\u0131l\u0131\u011f\u0131n\u0131 be\u015f farkl\u0131 ticari SMD test kiti (Sensititre\u2122<\/sup><\/span>, MICRONAUT-S, MICRONAUT MIC-Strip, SensiTest ve UMIC) ve iki gradyan test (Etest and MIC Test Strip) ile saptayarak, sonu\u00e7lar\u0131 bu izolatlar\u0131n referans agar dil\u00fcsyon y\u00f6ntemi ile elde edilen kolistin duyarl\u0131l\u0131k sonu\u00e7lar\u0131 ile kar\u015f\u0131la\u015ft\u0131ran ba\u015fka bir \u00e7al\u0131\u015fmada ise Sensititre\u2122<\/sup><\/span> y\u00f6ntemi i\u00e7in KU oran\u0131 %91, \u00c7BH oran\u0131 %0 ve BH oran\u0131 %2 olarak bulunmu\u015ftur (16). Janet ve arkada\u015flar\u0131n\u0131n (17) \u00e7al\u0131\u015fmas\u0131nda, SMD referans y\u00f6ntemine g\u00f6re Sensititre\u2122<\/sup><\/span> y\u00f6ntemi i\u00e7in KU oran\u0131 %96, \u00c7BH oran\u0131 %0 ve BH oran\u0131 %5 olarak tespit edilmi\u015ftir. \u00dclkemizde yap\u0131lan bir \u00e7al\u0131\u015fmada karbapenem diren\u00e7li Gram-negatif bakterilerde kolistin i\u00e7in Sensititre\u2122<\/sup><\/span> panelinin referans y\u00f6ntem ile KU oran\u0131 %94.9, \u00c7BH ve BH oranlar\u0131 s\u0131ras\u0131 ile %7.1 ve %4.5 olarak tespit edilmi\u015ftir (18). \u00c7al\u0131\u015fmam\u0131zda ise, di\u011fer \u00e7al\u0131\u015fmalardan farkl\u0131 olarak Sensititre\u2122<\/sup><\/span> y\u00f6nteminde KU oran\u0131 %68, \u00c7BH oran\u0131 %5 ve BH oran\u0131 %27 olarak tespit edildi. Elde etti\u011fimiz sonu\u00e7lar\u0131n ISO taraf\u0131ndan belirlenen kriterlere g\u00f6re kabul edilebilir performansta olmad\u0131\u011f\u0131 g\u00f6r\u00fcld\u00fc (7).<\/p>\n

\u00c7al\u0131\u015fmam\u0131zda; Sensititre\u2122<\/sup><\/span> y\u00f6ntemindeki kategorik uyumun d\u00fc\u015f\u00fckl\u00fc\u011f\u00fcne, y\u00f6ntemin referans testten daha d\u00fc\u015f\u00fck ve referans testten daha y\u00fcksek olan, M\u0130K kesme noktas\u0131 referans testin \u00e7evresinde M\u0130K de\u011ferine sahip izolatlar neden olmu\u015ftur. Sensititre\u2019nin referans testten daha d\u00fc\u015f\u00fck, M\u0130K kesme noktas\u0131 referans testin \u00e7evresinde M\u0130K de\u011ferine sahip be\u015f izolat bulunmaktad\u0131r (SMD MIK 4; Sensititre\u2122<\/sup><\/span> MIK 2). Bu e\u011filim, Matuschek ve arkada\u015flar\u0131n\u0131n (16) \u00e7al\u0131\u015fmas\u0131n\u0131n yan\u0131 s\u0131ra Yusuf ve arkada\u015flar\u0131n\u0131n (19) \u00e7al\u0131\u015fmas\u0131nda da g\u00f6r\u00fclm\u00fc\u015ft\u00fcr. Sensititre\u2019nin referans testten daha y\u00fcksek ve M\u0130K kesme noktas\u0131 referans testin \u00e7evresinde M\u0130K de\u011ferine sahip olan 25 izolat bulunmaktad\u0131r (SMD MIK 2; Sensititre MIK 4). Bu iki durum normalde olas\u0131 teknik hatalar i\u00e7in bir tampon b\u00f6lge olarak kullan\u0131lan EUCAST ve CLSI \u201cbreakpoint\u201d tablolar\u0131nda orta de\u011fer (\u201cintermediate\u201d) kategorisinin olmamas\u0131yla a\u00e7\u0131klanabilir. Ayr\u0131ca M\u0130K de\u011feri s\u0131n\u0131r de\u011fere yakla\u015ft\u0131k\u00e7a, \u00c7BH ya da BH oranlar\u0131n\u0131n artt\u0131\u011f\u0131 Matuschek ve arkada\u015flar\u0131n\u0131n (16) \u00e7al\u0131\u015fmas\u0131nda da bildirilmi\u015ftir.<\/p>\n

T\u00fczemen ve arkada\u015flar\u0131n\u0131n (20) yapm\u0131\u015f oldu\u011fu \u00e7al\u0131\u015fmada, BD Phoenix\u2122<\/sup><\/span> 100 otomatize sisteminin A. baumannii <\/i>i\u00e7in kolistin duyarl\u0131l\u0131\u011f\u0131n\u0131n belirlenmesinde referans y\u00f6nteme g\u00f6re KU oran\u0131 %77.8, \u00c7BH oran\u0131 %0 ve BH oran\u0131 %22.2 olarak tespit edilmi\u015ftir. Vourli ve arkada\u015flar\u0131 (21) taraf\u0131ndan yap\u0131lan \u00e7al\u0131\u015fmada, kolistin duyarl\u0131l\u0131\u011f\u0131n\u0131n belirlenmesinde kullan\u0131lan BD Phoenix\u2122<\/sup><\/span> 100 otomatize sisteminin \u00c7BH oran\u0131 %41.4 olarak tespit edilmi\u015ftir. \u00dclkemizde yap\u0131lan bir \u00e7al\u0131\u015fman\u0131n verilerine g\u00f6re, BD Phoenix\u2122<\/sup><\/span> 100 otomatize sisteminin referans y\u00f6nteme g\u00f6re A. baumannii <\/i>i\u00e7in kolistinin \u00c7BH oran\u0131 %71.4 olarak saptanm\u0131\u015f; BH ise g\u00f6zlenmemi\u015ftir (22). \u00c7al\u0131\u015fmam\u0131zda BD Phoenix\u2122<\/sup><\/span> 100 i\u00e7in kolistin sonu\u00e7lar\u0131n\u0131 SMD y\u00f6ntemi ile kar\u015f\u0131la\u015ft\u0131rd\u0131\u011f\u0131m\u0131zda KU oran\u0131 %79, BH oran\u0131 %10, \u00c7BH oran\u0131 %11 olarak bulundu. BD Phoenix\u2122<\/sup><\/span> 100 otomatize sisteminden elde etti\u011fimiz kolistin duyarl\u0131l\u0131k sonu\u00e7lar\u0131n\u0131n yap\u0131lan \u00e7al\u0131\u015fmalarla uyumlu oldu\u011fu ve ISO taraf\u0131ndan belirlenen kriterlere g\u00f6re kabul edilebilir performansta olmad\u0131\u011f\u0131 g\u00f6r\u00fcld\u00fc (7). BD Phoenix\u2122<\/sup><\/span> 100 ile kolistin duyarl\u0131 ya da diren\u00e7li tespit edilen su\u015flar\u0131n BMD y\u00f6ntemi ile do\u011frulanmas\u0131 gerekmektedir.<\/p>\n

Osei ve arkada\u015flar\u0131 (23) yapm\u0131\u015f olduklar\u0131 \u00e7al\u0131\u015fmada, MicroScan WalkAway<\/span>\u2122<\/sup><\/span> otomatize sistemini, SMD y\u00f6ntemi ile kar\u015f\u0131la\u015ft\u0131rd\u0131klar\u0131nda; Enterobacter cloacae, Salmonella<\/i> ve non-fermanter Gram-negatif bakteriler (Pseudomonas <\/i>hari\u00e7) d\u0131\u015f\u0131ndaki Gram-negatif bakteriler i\u00e7in, kolistine diren\u00e7li izolatlar\u0131n %92.31\u2019inin tespit edilebildi\u011fini, \u00f6zg\u00fcll\u00fc\u011f\u00fcn ise %76.92 oldu\u011funu belirtmi\u015ftir. Ancak non-fermanter bakteriler i\u00e7in MicroScan WalkAway<\/span>\u2122<\/sup><\/span> otomatize sisteminden elde edilen kolistin duyarl\u0131l\u0131k sonu\u00e7lar\u0131n\u0131n do\u011frulanmas\u0131 amac\u0131yla SMD y\u00f6nteminin kullan\u0131lmas\u0131n\u0131 \u00f6nermi\u015flerdir. Acinetobacter<\/i> spp. izolatlar\u0131yla agar dil\u00fcsyon y\u00f6ntemini alt\u0131n standart kabul ederek VITEK\u00ae<\/sup> 2, MicroScan WalkAway<\/span>\u2122<\/sup><\/span>, Etest\u00ae y\u00f6ntemlerinin kolistine duyarl\u0131l\u0131klar\u0131n\u0131n kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131 ba\u015fka bir \u00e7al\u0131\u015fmada ise, MicroScan WalkAway<\/span>\u2122<\/sup><\/span> otomatize sisteminin A. baumannii <\/i>i\u00e7in KU oran\u0131 % 95.7, \u00c7BH oran\u0131 %0 ve BH oran\u0131 %4.3 olarak bulunmu\u015ftur (24). \u00dclkemizde yap\u0131lan bir \u00e7al\u0131\u015fmada, karbapenem diren\u00e7li Enterobacteriaceae<\/i> izolatlar\u0131nda MicroScan WalkAway<\/span>\u2122<\/sup><\/span> sistemi referans y\u00f6ntem ile kar\u015f\u0131la\u015ft\u0131rarak kolistin duyarl\u0131l\u0131\u011f\u0131 KU oran\u0131 %90, \u00c7BH oran\u0131 %7.5 ve BH oran\u0131 %2.5 olarak tespit edilmi\u015ftir (25). \u00c7al\u0131\u015fmam\u0131zda, A. baumannii <\/i>izolatlar\u0131nda MicroScan WalkAway<\/span>\u2122<\/sup><\/span> sistemi, SMD y\u00f6ntemi alt\u0131n standart kabul edildi\u011finde, KU oran\u0131 %97, \u00c7BH oran\u0131 %2 ve BH oran\u0131 %1 olarak tespit edildi; ISO taraf\u0131ndan belirlenen kriterlere g\u00f6re de kabul edilebilir performanstayd\u0131 (7).<\/span><\/p>\n

CLSI-EUCAST Polimiksin E\u015fik De\u011fer Belirleme \u00c7al\u0131\u015fma Grubu, ISO 20776:1 standard\u0131na g\u00f6re kolistin duyarl\u0131l\u0131\u011f\u0131n\u0131n belirlenmesi i\u00e7in SMD y\u00f6ntemini \u201creferans y\u00f6ntem\u201d olarak kabul etmi\u015ftir (3). G\u00fcn\u00fcm\u00fczde de tek ge\u00e7erli y\u00f6ntem olan s\u0131v\u0131 mikrodil\u00fcsyon ile farkl\u0131 y\u00f6ntemlerin kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131 \u00e7al\u0131\u015fmalar yap\u0131lmaktad\u0131r. Ancak ticari olarak \u00fcretilen otomatize ve manuel sistemlerin s\u0131v\u0131 mikrodil\u00fcsyon ile kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131 \u00e7al\u0131\u015fmalar\u0131n say\u0131s\u0131 az olup bu \u00e7al\u0131\u015fmalardan farkl\u0131 sonu\u00e7lar al\u0131nm\u0131\u015ft\u0131r. \u00c7al\u0131\u015fmam\u0131z\u0131n verilerine g\u00f6re; kolistin direncinin SMD y\u00f6ntemiyle do\u011frulanamad\u0131\u011f\u0131 durumlarda, MicroScan WalkAway<\/span>\u2122 <\/sup><\/span>otomatize sisteminin M\u0130K de\u011ferleri kabul edilebilir bulundu. Ancak, Mikroscan WalkAway<\/span>\u2122<\/sup><\/span> sistemi de dahil olmak \u00fczere t\u00fcm ticari mikrodil\u00fcsyon y\u00f6ntemlerinin kullan\u0131ld\u0131\u011f\u0131 durumlarda sonu\u00e7lar\u0131n daha dikkatli olarak de\u011ferlendirilmesi ve testlerin kalite kontrollerinin standartlara uygun ve d\u00fczenli olarak yap\u0131lmas\u0131 uygun olacakt\u0131r.<\/span><\/p>\n

Sonu\u00e7 olarak; laboratuvar \u00e7al\u0131\u015fmalar\u0131nda kolistin duyarl\u0131l\u0131\u011f\u0131n\u0131n tespiti i\u00e7in alt\u0131n standart olarak kullan\u0131lan ticari y\u00f6ntemlerin (gerek cihaz gerekse M\u0130K y\u00f6ntemleri) SMD y\u00f6ntemi baz al\u0131narak uluslararas\u0131 k\u0131lavuzlara uyumlu hale getirilmesi i\u00e7in optimize ve standardize edilmesi gerekmektedir.<\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e Acinetobacter baumannii, \u00f6zellikle yo\u011fun bak\u0131m \u00fcnitelerinde artan morbidite ve mortalite ile ili\u015fkili ciddi hastane infeksiyonlar\u0131ndan giderek daha fazla sorumlu tutulmaktad\u0131r. Kolistin, ilk olarak 1949\u2019da Paenibacillus polymyxa\u2019dan izole edilmi\u015f olup A\u2019dan E\u2019ye kadar be\u015f farkl\u0131 yap\u0131sal analo\u011fa sahiptir; polimiksin B ve E (kolistin) klinik kullan\u0131mda olanlard\u0131r. Bir ekzosiklik zincir, bir heptapeptit halkas\u0131 ve pozitif y\u00fckl\u00fc […]<\/p>\n","protected":false},"author":4,"featured_media":25605,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[5504,4303,5503,5312,5311],"class_list":["post-25437","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ozgun-arastirma","tag-acinetobacter-baumannii-2","tag-kolistin","tag-otomatize-sistemler","tag-sensititre","tag-sivi-mikrodilusyon"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25437","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\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=25437"}],"version-history":[{"count":4,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25437\/revisions"}],"predecessor-version":[{"id":25728,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25437\/revisions\/25728"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/25605"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=25437"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=25437"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=25437"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}