{"id":25450,"date":"2022-09-28T09:00:27","date_gmt":"2022-09-28T06:00:27","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=25450"},"modified":"2022-09-28T11:46:42","modified_gmt":"2022-09-28T08:46:42","slug":"pnomoni-hastalarinda-mikrobiyal-etyoloji","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2022\/09\/28\/pnomoni-hastalarinda-mikrobiyal-etyoloji\/","title":{"rendered":"A\u011f\u0131r Pn\u00f6moni Tan\u0131l\u0131 Hastalar\u0131n Endotrakeal Aspirat \u00d6rne\u011finde Pn\u00f6moni Etkenlerinin K\u00fclt\u00fcr ve Multipleks Polimeraz Zincir Reaksiyonu Y\u00f6ntemi ile Ara\u015ft\u0131r\u0131lmas\u0131"},"content":{"rendered":"<h2 class=\"p1\">G\u0130R\u0130\u015e<\/h2>\n<p class=\"p2\">Pn\u00f6moniler, t\u00fcm d\u00fcnyada ciddi bir morbidite ve mortalite sebebidir. Koronavirus hastal\u0131\u011f\u0131 2019 (COVID-19) pandemisi gibi d\u00fcnya genelinde meydana gelen salg\u0131nlar, pn\u00f6moni patogenezini anlaman\u0131n, tedavinin ve \u00f6nlem protokolleri olu\u015fturman\u0131n \u00f6nemini ortaya koymaktad\u0131r. A\u015f\u0131lama programlar\u0131 ile bir\u00e7ok geli\u015fmi\u015f \u00fclkede toplum k\u00f6kenli pn\u00f6mokok ve <i>Haemophilus influenzae<\/i>\u00a0tip b pn\u00f6monisi oranlar\u0131nda d\u00fc\u015f\u00fc\u015f kaydedilmekle birlikte \u00f6zellikle diren\u00e7li Gram-negatif bakterilere ba\u011fl\u0131 hastane kaynakl\u0131 pn\u00f6monilerin artmas\u0131 ciddi bir sa\u011fl\u0131k sorunu haline gelmi\u015ftir (1). Pn\u00f6moni etkenlerinin da\u011f\u0131l\u0131mlar\u0131 \u00fclkeler aras\u0131nda ve bir \u00fclkenin farkl\u0131 b\u00f6lgelerinde ayn\u0131 olmayabilir. Son y\u0131llarda kullan\u0131ma giren molek\u00fcler y\u00f6ntemlerle; viral\u00a0ve\u00a0di\u011fer atipik\u00a0pn\u00f6moni etkenlerinin (bakteri, mantarlar) saptanma olas\u0131l\u0131klar\u0131 artm\u0131\u015ft\u0131r. Bu testlerin rutin kullan\u0131ma girmesi; hastalar\u0131n tan\u0131 ve tedavi s\u00fcre\u00e7lerine destek olman\u0131n yan\u0131 s\u0131ra gerekli olmayan durumlarda antibiyotik kullan\u0131m\u0131n\u0131n \u00f6n\u00fcne de ge\u00e7erek antibiyotik direncinin azalmas\u0131na katk\u0131 sa\u011flayabilir (2).<\/p>\n<p class=\"p3\">Klinik pratikte pn\u00f6moni hastalar\u0131nda etyolojiyi belirlemeye y\u00f6nelik testlerin \u00e7o\u011funlukla uygulanmamas\u0131 ve uygulanan testlerin de birka\u00e7 g\u00fcn i\u00e7inde sonu\u00e7lanmas\u0131 nedeniyle tedavi \u00e7o\u011fu kez ampirik olarak ba\u015flat\u0131lmaktad\u0131r. Hastalarda uygun olmayan ampirik antibiyotik tedavisi; antibiyotik direncine ve istenmeyen yan etkilere neden olabilmektedir. Atipik pn\u00f6moni etkeni olan bakterilerin (<i>Mycoplasma pneumoniae, <\/i>vb<i>.<\/i>) beta-laktam antibiyotiklerden etkilenmemesi ve viral pn\u00f6monilerde etkili olabilecek baz\u0131 antivirallerin kullan\u0131lmamas\u0131 tedavi ba\u015far\u0131s\u0131zl\u0131klar\u0131na neden olmaktad\u0131r.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\"><span class=\"s1\">Son y\u0131llarda geli\u015ftirilen molek\u00fcler y\u00f6ntemlerle birlikte viruslar\u0131n pn\u00f6monideki rol\u00fc \u00f6n plana \u00e7\u0131km\u0131\u015ft\u0131r. Bir\u00e7ok virus sadece toplum k\u00f6kenli pn\u00f6moni (TKP) ile de\u011fil hastane k\u00f6kenli pn\u00f6moni (HKP) ve ventilat\u00f6r ili\u015fkili pn\u00f6moni (V\u0130P) ile de ili\u015fkili bulunmu\u015ftur (3, 4). Molek\u00fcler y\u00f6ntemler \u00e7o\u011funlukla nazofarenks \u00f6rneklerinden \u00e7al\u0131\u015f\u0131lmaktad\u0131r; bir\u00e7ok \u00e7al\u0131\u015fma nazofarenks \u00f6rneklerinin alt solunum yolu infeksiyonu etkenlerini saptama a\u00e7\u0131s\u0131ndan yanl\u0131\u015f negatiflik ve yanl\u0131\u015f pozitiflik ile sonu\u00e7lanabilece\u011fini g\u00f6stermi\u015ftir (5, 6).<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p3\">\u00dclkemizde, mekanik\u00a0ventilat\u00f6r\u00a0alt\u0131nda takip edilen pn\u00f6moni hastalar\u0131nda, etkenleri endotrakeal aspirasyon \u00f6rne\u011finde (ETA) multipleks-PCR (m-PCR) ile saptamaya y\u00f6nelik olarak yap\u0131lm\u0131\u015f s\u0131n\u0131rl\u0131 say\u0131da \u00e7al\u0131\u015fma mevcuttur.<\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fmam\u0131zda; TKP, HKP ve V\u0130P hastalar\u0131nda pn\u00f6moni etkenlerinin ETA \u00f6rneklerinde m-PCR y\u00f6ntemi ve konvansiyonel y\u00f6ntemlerden biri olan bakteriyolojik k\u00fclt\u00fcr y\u00f6ntemiyle e\u015f zamanl\u0131 ara\u015ft\u0131r\u0131lmas\u0131 ama\u00e7land\u0131.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<h2 class=\"p1\">Y\u00d6NTEMLER<\/h2>\n<p class=\"p3\">\u00c7al\u0131\u015fma, hastanemizin Anestezi ve Reanimasyon Yo\u011fun Bak\u0131m,\u00a0Beyin ve Sinir Cerrahi Yo\u011fun Bak\u0131m, Kalp ve Damar Cerrahi Yo\u011fun Bak\u0131m, N\u00f6roloji Yo\u011fun Bak\u0131m, Genel Dahiliye Yo\u011fun Bak\u0131m ve Acil Yo\u011fun Bak\u0131m \u00fcnitelerinde 10 Aral\u0131k 2019\u00a0\u2013 02 Kas\u0131m 2020 tarihleri aras\u0131nda ger\u00e7ekle\u015ftirildi. Yo\u011fun bak\u0131m \u00fcnitelerinde yatan 18 ya\u015f ve \u00fczeri TKP ve HKP\u00a0tan\u0131s\u0131 alan ve a\u011f\u0131r pn\u00f6moni olarak de\u011ferlendirilen hastalar \u00e7al\u0131\u015fmaya dahil edildi.\u00a0 A\u011f\u0131r pn\u00f6moni kriteri, hastalar\u0131n mekanik ventilat\u00f6re ba\u011fl\u0131 olmas\u0131yd\u0131.<\/p>\n<p class=\"p3\">TKP tan\u0131s\u0131; Amerikan \u0130nfeksiyon Hastal\u0131klar\u0131 Derne\u011fi \u201c(Infectious Disease Society of America \u2013 IDSA\u201d) ve Amerikan Toraks Derne\u011fi (\u201cAmerican Thoracic Society \u2013 ATS\u201d)\u2019nin Toplum K\u00f6kenli Pn\u00f6moni Y\u00f6netimi 2007 Y\u0131l\u0131 Rehberi; HKP tan\u0131s\u0131 IDSA-ATS Hastane Kaynakl\u0131 Pn\u00f6moni Y\u00f6netimi 2016 Y\u0131l\u0131 Rehberi; V\u0130P tan\u0131s\u0131 ise ADB Hastal\u0131k Kontrol ve Korunma Merkezleri (\u201cCenters for Disease Control and Prevention \u2013 CDC\u201d) kriterlerine uygun olarak koyuldu.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">Olgular\u0131n \u00e7al\u0131\u015fma d\u0131\u015f\u0131 b\u0131rak\u0131lma kriterleri a\u015fa\u011f\u0131daki gibi belirlendi:<\/p>\n<ul>\n<li class=\"p5\">18 ya\u015f alt\u0131 olan hastalar,<\/li>\n<li class=\"p5\">Akci\u011fer\u00a0malignitesi\u00a0tan\u0131s\u0131 alan hastalar,<\/li>\n<li class=\"p5\">Solid organ transplantasyonu yap\u0131lanlar ve hematopoetik k\u00f6k h\u00fccre al\u0131c\u0131lar\u0131,<span class=\"Apple-converted-space\">\u00a0<\/span><\/li>\n<li class=\"p5\">HIV pozitif olan hastalar,<\/li>\n<li class=\"p5\">\u015eiddetli akut solunum sendromu koronavirus 2 (SARS-Cov2) PCR testi pozitif olan\u00a0hastalar,<\/li>\n<li class=\"p5\">SARS-Cov2 PCR testi negatif olmas\u0131na kar\u015f\u0131n akci\u011fer tomografisinde COVID-19<span class=\"Apple-converted-space\">\u00a0 <\/span>pn\u00f6monisi ile uyumlu g\u00f6r\u00fcn\u00fcm olan hastalar,<\/li>\n<li class=\"p5\">Pn\u00f6moniye\u00a0y\u00f6nelik olarak ba\u015flat\u0131lan tedavinin 48. saatini doldurmu\u015f olan hastalar,<\/li>\n<li class=\"p5\">Tedavinin 48. saatinden sonra ent\u00fcbe olan hastalar.<\/li>\n<\/ul>\n<p class=\"p3\">\u00c7al\u0131\u015fmaya al\u0131nacak hastalara g\u00fcnl\u00fck yo\u011fun bak\u0131m\u00a0viziti\u00a0yap\u0131ld\u0131. Pn\u00f6moni \u00f6ncesinde ya da tan\u0131n\u0131n ilk 48 saatinde ent\u00fcbe olan hastalardan hem rutin mikrobiyolojik k\u00fclt\u00fcr hem de PCR testi \u00e7al\u0131\u015f\u0131lmas\u0131 i\u00e7in iki ETA \u00f6rne\u011fi al\u0131nd\u0131. Al\u0131nan \u00f6rneklere homojen olmas\u0131 a\u00e7\u0131s\u0131ndan alt solunum yolu \u00f6rne\u011fi olarak bronkoalveolar lavaj (BAL) ve benzeri \u00f6rnekler dahil edilmedi. <span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">Hastalar\u0131n di\u011fer verileri hastane bilgi\u00a0y\u00f6netim\u00a0sistemi\u00a0kay\u0131tlar\u0131ndan elde edildi. Pn\u00f6moni tedavileri, hastay\u0131 ilk de\u011ferlendiren infeksiyon hastal\u0131klar\u0131 ve klinik mikrobiyoloji hekimi taraf\u0131ndan hastan\u0131n \u00f6zelliklerine uygun bir \u015fekilde ampirik olarak ba\u015flat\u0131ld\u0131. K\u00fclt\u00fcr ve m-PCR sonu\u00e7lar\u0131na g\u00f6re tedavi tekrar de\u011ferlendirildi.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">Hastalar\u0131n; demografik verileri,\u00a0altta yatan hastal\u0131klar\u0131, pn\u00f6moni tan\u0131s\u0131 ald\u0131\u011f\u0131 ilk 48 saat i\u00e7indeki laboratuvar ve mikrobiyolojik verileri kay\u0131t alt\u0131na al\u0131nd\u0131.\u00a0Tedavi ba\u015flang\u0131c\u0131ndan 48 saat sonra g\u00f6nderilen k\u00fclt\u00fcr ve m-PCR \u00f6rnekleri verilere dahil edilmedi. <span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">Hastalar; TKP, HKP ve V\u0130P olmak \u00fczere \u00fc\u00e7 grupta incelendi. V\u0130P olgular\u0131 etken farkl\u0131l\u0131\u011f\u0131 g\u00f6sterebilece\u011finden HKP grubuna dahil edilmeyip ayr\u0131 grup olarak de\u011ferlendirildi.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fmam\u0131zda; <i>M. pneumoniae<\/i>, <i>Legionella pneumophila<\/i> ve <i>Pneumocystis jirovecii<\/i> atipik pn\u00f6moni etkenleri olarak tan\u0131mland\u0131.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">Hastalardan al\u0131nan ETA \u00f6rnekleri, \u00f6nce steril serum fizyolojik ile e\u015fit hacimde bire bir suland\u0131r\u0131ld\u0131 ve koyun kanl\u0131 agar, \u201ceozin-metilen blue\u201d (EMB) agar, \u00e7ikolata agar besiyerlerine kantitatif k\u00fclt\u00fcr y\u00f6ntemi ile ekimi yap\u0131ld\u0131. Kanl\u0131 agar ve EMB agar aerobik ortamda ve \u00e7ikolata agar mikroaerofilik ortamda olmak \u00fczere et\u00fcvde, 37 \u00b0C\u2019de 24-48 saat ink\u00fcbe edildikten sonra \u00fcreme olup olmad\u0131\u011f\u0131 de\u011ferlendirildi. ETA \u00f6rne\u011fi i\u00e7in kantitatif ekimde e\u015fik de\u011fer olan \u226510<span class=\"s2\"><sup>5<\/sup><\/span> CFU\/ml \u00fcreme elde edilen ve etken oldu\u011fu d\u00fc\u015f\u00fcn\u00fclen koloniler, VITEK<sup>\u00ae<\/sup> 2 otomatize sistemi (bioM\u00e9rieux, Marcy l\u2019Etoile, Fransa) ile tiplendirildi. Primer \u00f6rnekten ekimle e\u015f zamanl\u0131 preparat haz\u0131rlan\u0131p Gram boyama yap\u0131ld\u0131 ve etken\/kontaminant ayr\u0131m\u0131nda Gram boyama sonucu da de\u011ferlendirildi.<\/p>\n<p class=\"p3\">Magnesia<span class=\"s2\">\u00ae <\/span>16 otomatik izolasyon sistemi (Anatolia Tan\u0131 ve Biyoteknoloji A.\u015e., T\u00fcrkiye)\u2019nde 202 viral panel kiti ve 502 bakteriyel DNA izolasyon kiti (Anatolia Tan\u0131 ve Biyoteknoloji A.\u015e., T\u00fcrkiye) kullan\u0131larak primer \u00f6rneklerden n\u00fckleik asit izolasyonu yap\u0131ld\u0131. Daha sonra elde edilen eluatlar; Montania<sup>\u00ae<\/sup> 4896 ger\u00e7ek zamanl\u0131 (\u201creal-time \u2013 RT\u201d) PCR cihaz\u0131 (Anatolia Tan\u0131 ve Biyoteknoloji A.\u015e.) ile Bosphore<sup>\u00ae<\/sup> solunum yolu patojenleri panel kiti V4 (Anatolia Tan\u0131 ve Biyoteknoloji A.\u015e.) kullan\u0131larak bakteriyel ve viral patojenler y\u00f6n\u00fcnden ara\u015ft\u0131r\u0131ld\u0131. RT PCR y\u00f6ntemi ile ara\u015ft\u0131r\u0131lan patojenler; influenza B, <i>M. pneumoniae<\/i>, <i>Klebsiella pneumoniae<\/i>, parainfluenza 2, parainfluenza 4, parainfluenza 1, metapn\u00f6movirus, enterovirus, influenza A, parainfluenza 3, respiratuar sinsityal virusu (RSV) A\/B, bocavirus, rhinovirus, koronavirus 229E, pandemik H1N1 influenza A, mevsimsel H1N1 influenza A, <i>Salmonella enterica<\/i>, adenovirus, <i>Moraxella catarrhalis<\/i>, <i>Bordetella pertussis<\/i>, <i>H. influenzae<\/i> tip B, parechovirus,<br \/>\n<i>Staphylococcus aureus, P. jiroveci, Streptococcus pneumoniae, L. pneumophila<\/i>, koronavirus OC43 ve koronavirus NL63 idi. Bosphore<span class=\"s2\">\u00ae<\/span> solunum yolu patojenleri panel kiti V4 (Anatolia Tan\u0131 ve Biyoteknoloji A.\u015e.) <i>Chlamydia pneumoniae\u2019i <\/i>i\u00e7ermedi\u011fi i\u00e7in bu etken ara\u015ft\u0131r\u0131lamad\u0131.<\/p>\n<p class=\"p3\"><span class=\"s3\">\u00c7al\u0131\u015fmada hastalar\u0131n beyaz kan h\u00fccresi say\u0131s\u0131 (WBC), C-reaktif protein (CRP) de\u011feri, n\u00f6trofil-lenfosit oran\u0131 (NLO), prokalsitonin (PCT), kreatin sonu\u00e7lar\u0131 da de\u011ferlendirildi. CRP de\u011feri, Cobas<\/span><span class=\"s4\">\u00ae<\/span><span class=\"s3\"> 6000 analiz\u00f6r serisi (Roche Diagnostics, ABD) kullan\u0131larak imm\u00fcnot\u00fcrbidimetrik metotla \u00f6l\u00e7\u00fcld\u00fc. PCT ise Cobas<\/span><span class=\"s4\">\u00ae<\/span><span class=\"s3\"> 400 plus otoanaliz\u00f6r sistemi ile elektrokemil\u00fcminesans imm\u00fcnolojik metotla \u00e7al\u0131\u015f\u0131ld\u0131. CRP i\u00e7in &lt;5 mg\/lt PCT i\u00e7in &lt;0.5 \u00b5l ve kreatinin&lt;1.2 mg\/dl de\u011ferleri normal olarak de\u011ferlendirildi.<\/span><\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fma i\u00e7in, Ankara E\u011fitim ve Ara\u015ft\u0131rma Hastanesi Etik Kurul Ba\u015fkanl\u0131\u011f\u0131\u2019ndan 20 \u015eubat 2020 tarih ve 218 karar numaras\u0131yla onay al\u0131nd\u0131. Ayr\u0131ca, hastalar veya yak\u0131nlar\u0131ndan bilgilendirilmi\u015f onam formu al\u0131nd\u0131.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<h3 class=\"p7\">\u0130statistiksel Analiz<\/h3>\n<p class=\"p3\"><span class=\"s5\">\u00d6rneklem b\u00fcy\u00fckl\u00fc\u011f\u00fc G* Power program\u0131 (<\/span><span class=\"s6\">Heinrich-Heine-Universit\u00e4t D\u00fcsseldorf, D\u00fcsseldorf, Almanya)<\/span><span class=\"s5\"> kullan\u0131larak hesapland\u0131. Tip 1 hata 0.05, tip 2 hata 0.95 olarak belirlenerek en az 120 ki\u015fiye ula\u015fmak hedeflendi.<\/span><span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">\u0130statistiksel analizler, SPSS (\u201cStatistical Package for the Social Sciences\u201d) versiyon 15.0 program\u0131 (IBM Corp., Armonk, NY, ABD) kullan\u0131larak yap\u0131ld\u0131. De\u011fi\u015fkenlerin normal da\u011f\u0131l\u0131ma uygunlu\u011fu g\u00f6rsel (histogram ve olas\u0131l\u0131k grafikleri) ve analitik y\u00f6ntemler (Kolmogorov-Smirnov ve Shapiro-Wilk testleri) kullan\u0131larak incelendi. T\u00fcm de\u011fi\u015fkenlerin, normal da\u011f\u0131lmayan de\u011fi\u015fkenler (non-parametrik) oldu\u011fu g\u00f6zlendi. Kategorik de\u011fi\u015fkenlerin de\u011ferlendirmesinde Pearson ki-kare testi ve Fisher kesin testi uyguland\u0131. \u0130ki ba\u011f\u0131ms\u0131z grubun ortalamalar\u0131n\u0131n kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131nda Mann-Whitney U testi; \u00fc\u00e7 grubun ortalamalar\u0131n\u0131n kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131nda ba\u011f\u0131ms\u0131z de\u011fi\u015fkenler i\u00e7in Kruskall-Wallis testi uyguland\u0131. \u0130statistiksel olarak anlaml\u0131 sonu\u00e7lar, Bonferroni d\u00fczeltmesi uygulanarak ve gruplar aras\u0131nda ikili kar\u015f\u0131la\u015ft\u0131rmalar yap\u0131larak belirlendi. Sonu\u00e7lar %95 g\u00fcven aral\u0131\u011f\u0131nda ve istatistiksel anlaml\u0131l\u0131k d\u00fczeyi p&lt;0.05 olarak kabul edildi.<\/p>\n<h2 class=\"p1\">BULGULAR<\/h2>\n<div id=\"attachment_25630\" style=\"width: 1077px\" class=\"wp-caption alignright\"><a href=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-1.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-25630\" class=\"wp-image-25630 size-full\" src=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-1.png\" alt=\"\" width=\"1067\" height=\"1843\" srcset=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-1.png 1067w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-1-151x260.png 151w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-1-313x540.png 313w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-1-768x1327.png 768w\" sizes=\"auto, (max-width: 1067px) 100vw, 1067px\" \/><\/a><p id=\"caption-attachment-25630\" class=\"wp-caption-text\"><strong> Tablo 1.<\/strong> Hastalar\u0131n ETA \u00d6rne\u011finin Multipleks PCR Sonu\u00e7lar\u0131<\/p><\/div>\n<div id=\"attachment_25632\" style=\"width: 1078px\" class=\"wp-caption alignright\"><a href=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-2.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-25632\" class=\"wp-image-25632 size-full\" src=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-2.png\" alt=\"\" width=\"1068\" height=\"2052\" srcset=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-2.png 1068w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-2-135x260.png 135w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-2-281x540.png 281w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-2-768x1476.png 768w\" sizes=\"auto, (max-width: 1068px) 100vw, 1068px\" \/><\/a><p id=\"caption-attachment-25632\" class=\"wp-caption-text\"><strong> Tablo 2.<\/strong> Hastalar\u0131n ETA \u00d6rne\u011fi K\u00fclt\u00fcr Sonu\u00e7lar\u0131<\/p><\/div>\n<div id=\"attachment_25634\" style=\"width: 1078px\" class=\"wp-caption alignright\"><a href=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-3.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-25634\" class=\"wp-image-25634 size-full\" src=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-3.png\" alt=\"\" width=\"1068\" height=\"2024\" srcset=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-3.png 1068w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-3-137x260.png 137w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-3-285x540.png 285w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-3-768x1455.png 768w\" sizes=\"auto, (max-width: 1068px) 100vw, 1068px\" \/><\/a><p id=\"caption-attachment-25634\" class=\"wp-caption-text\"><strong> Tablo 3.<\/strong> Hastalar\u0131n Kan K\u00fclt\u00fcr\u00fc Sonu\u00e7lar\u0131<\/p><\/div>\n<div id=\"attachment_25636\" style=\"width: 2196px\" class=\"wp-caption alignright\"><a href=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-4.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-25636\" class=\"wp-image-25636 size-full\" src=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-4.png\" alt=\"\" width=\"2186\" height=\"1001\" srcset=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-4.png 2186w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-4-390x179.png 390w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-4-810x371.png 810w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2022\/09\/KD.C35.S3_4004_TABLO-4-768x352.png 768w\" sizes=\"auto, (max-width: 2186px) 100vw, 2186px\" \/><\/a><p id=\"caption-attachment-25636\" class=\"wp-caption-text\"><strong> Tablo 4.<\/strong> Atipik Etken Pozitif Saptanan Hastalar\u0131n Mikrobiyolojik Verileri<\/p><\/div>\n<p class=\"p3\">Ara\u015ft\u0131rmaya %41\u2019i kad\u0131n ve %59\u2019u erkek olmak \u00fczere toplam 74 hasta al\u0131nd\u0131; ya\u015f ortancas\u0131 67.5 ya\u015ft\u0131 (19-93). V\u0130P hastalar\u0131n\u0131n say\u0131s\u0131 33 (%44.6), TKP hastalar\u0131n\u0131n say\u0131s\u0131 28 (%378) ve HKP hastalar\u0131n\u0131n say\u0131s\u0131 13 (%17.6)\u2019t\u00fc.<\/p>\n<p class=\"p3\">Hastalar\u0131n; 29 (%36)\u2019unun hipertansiyon (HT), 23(%32)\u2019\u00fcn\u00fcn intrakranial kanama (\u0130KK), 24 (%32)\u2019\u00fcn\u00fcn koroner arter hastal\u0131\u011f\u0131 (KAH), 21(%28)\u2019inin diabetes mellitus (DM), 15 (%21.3)\u2019inin kronik obstr\u00fcktif akci\u011fer hastal\u0131\u011f\u0131 (KOAH), 16 (%21.3)\u2019s\u0131nda kanama d\u0131\u015f\u0131 serebrovask\u00fcler olay (SVO), 8 (%10.7)\u2019inin konjestif kalp yetmezli\u011fi (KKY) ve 4 (%5.3)\u2019\u00fcn\u00fcn kronik b\u00f6brek hastal\u0131\u011f\u0131 (KBH) tan\u0131s\u0131 mevcuttu.<\/p>\n<p class=\"p3\">m-PCR ile 74 hastan\u0131n 65 (%87.8)\u2019inde etken saptand\u0131. ETA \u00f6rne\u011fi k\u00fclt\u00fcr\u00fc ile hastalar\u0131n 43 (%58.1)\u2019\u00fcnde \u00fcreme oldu. ETA \u00f6rneklerinde, hastalar\u0131n 28 (%37.8)\u2019inde PCR testi\u00a0polimikrobiyal\u00a0olarak sonu\u00e7land\u0131. PCR ile hem TKP hem HKP hastalar\u0131nda en s\u0131k\u00a0<i>S.\u00a0pneumoniae\u00a0<\/i>saptan\u0131rken V\u0130P hastalar\u0131nda en s\u0131k\u00a0<i>Klebsiella\u00a0<\/i>spp. saptand\u0131<i>.<\/i>\u00a0Hastalar\u0131n ETA k\u00fclt\u00fcr sonu\u00e7lar\u0131na bak\u0131ld\u0131\u011f\u0131nda; TKP ve HKP hastalar\u0131nda en s\u0131k\u00a0<i>S.\u00a0aureus<\/i>, V\u0130P hastalar\u0131nda en s\u0131k\u00a0<i>Klebsiella\u00a0<\/i>spp. \u00fcredi\u011fi\u00a0g\u00f6r\u00fcld\u00fc.\u00a0Hastalar\u0131n; ETA \u00f6rne\u011finin m-PCR sonu\u00e7lar\u0131 Tablo1\u2019de, ETA \u00f6rne\u011fi k\u00fclt\u00fcr sonu\u00e7lar\u0131 Tablo 2\u2019de, kan k\u00fclt\u00fcr sonu\u00e7lar\u0131 Tablo3\u2019te verilmi\u015ftir<span class=\"s7\">.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p3\">Toplam hasta say\u0131s\u0131n\u0131n 11 (%14.9)\u2019inde atipik pn\u00f6moni etkeni saptan\u0131rken TKP hastalar\u0131n\u0131n 8 (%28.5)\u2019inde ve HKP hastalar\u0131n\u0131n 3 (%23)\u2019\u00fcnde ayn\u0131 etken saptand\u0131. HKP hastalar\u0131nda saptanan 3 atipik etkenin 2\u2019si influenza virusuydu. m-PCR y\u00f6ntemiyle ETA \u00f6rneklerinde viral etken saptanan hastalar\u0131n %44.4\u2019\u00fcne bakteriyel etkenler de e\u015flik etmekteydi. V\u0130P tan\u0131l\u0131 hastalar\u0131n hi\u00e7birinde atipik etken saptanmad\u0131. Atipik etken saptanan t\u00fcm hastalar\u0131n mikrobiyolojik verileri Tablo 4\u2019te g\u00f6sterilmi\u015ftir.<\/p>\n<p class=\"p3\"><span class=\"s1\">Atipik etkenlerin %81.8\u2019inden viruslar\u0131n sorumlu oldu\u011fu g\u00f6r\u00fcld\u00fc. Saptanan viral etkenlerin %55.5\u2019inden de influenza A sorumluydu. \u0130nfluenza saptanan hastalar\u0131n %40\u2019\u0131n\u0131n hem kan hem ETA \u00f6rne\u011fi k\u00fclt\u00fcr\u00fcnde <i>S. aureus<\/i> \u00fcremesi mevcuttu.<\/span><\/p>\n<p class=\"p3\">Atipik pn\u00f6moni hastalar\u0131n\u0131n ya\u015f ortanca de\u011feri 58, tipik pn\u00f6moni hastalar\u0131n\u0131n ya\u015f ortanca de\u011feri ise 69\u2019du; iki grup aras\u0131nda ya\u015f a\u00e7\u0131s\u0131ndan istatiksel olarak anlaml\u0131 d\u00fczeyde farkl\u0131l\u0131k saptanmad\u0131 (p=0.15).<\/p>\n<p class=\"p3\">Hastalar TKP, HKP ve V\u0130P olarak gruplanarak kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda; ya\u015f, WBC, NLO, PCT ve kreatinin de\u011ferleri aras\u0131nda istatistiksel olarak anlaml\u0131 d\u00fczeyde fark bulunmad\u0131 (<i>p<\/i>&gt;0.05).<\/p>\n<p class=\"p3\">CRP de\u011feri ortancalar\u0131; TKP olan hastalar\u0131n 91.0 mg\/dl (11-376), HKP olan hastalar\u0131n 137.0 mg\/dl (17.0-354) ve V\u0130P olan hastalar\u0131n 190.0 mg\/dl (28.0-454.0) olarak bulundu (<i>p<\/i>=0.036). Yap\u0131lan ikili testlerde istatistiksel fark\u0131n TKP ile V\u0130P hastalar\u0131 aras\u0131nda oldu\u011fu tespit edildi.<\/p>\n<p class=\"p3\">Hastalar tipik-atipik pn\u00f6moni etkenlerine g\u00f6re grupland\u0131r\u0131larak kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda; ya\u015f, WBC, NLO, CRP, sedimantasyon, kreatinin de\u011ferleri aras\u0131nda istatistiksel olarak anlaml\u0131 d\u00fczeyde bir fark saptanmad\u0131 (<i>p<\/i>&gt;0.05). PCT de\u011ferleri kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda tipik pn\u00f6monili hastalar\u0131n ortanca de\u011feri 0.7 (0.07-100) iken atipik pn\u00f6monili hastalar\u0131n ortanca de\u011feri 12.9 (0.40-58.0) olarak bulundu (<i>p<\/i>=0.002).<\/p>\n<p class=\"p3\">Hastalar\u0131n; Alzheimer, DM, KAH, HT, SVO, \u0130KK, KOAH ve KBH gibi komorbiditeleri ile pn\u00f6moni etken tipi aras\u0131nda istatistiksel olarak anlaml\u0131 d\u00fczeyde fark bulunmad\u0131 (<i>p<\/i>&gt;0.05). HKP veya V\u0130P olan hastalar\u0131n %6.5\u2019inde atipik etken bulunurken, TKP hastalar\u0131n\u0131n %28.5\u2019inde atipik etken saptand\u0131 (<i>p<\/i>=0.016). <span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<h2 class=\"p1\">\u0130RDELEME<\/h2>\n<p class=\"p3\">Pn\u00f6moni hastalar\u0131nda mikrobiyal etyolojiye y\u00f6nelik bir\u00e7ok \u00e7al\u0131\u015fma bulunmaktad\u0131r. Bununla birlikte, pn\u00f6moni etyolojisine y\u00f6nelik HKP ve V\u0130P hastalar\u0131n\u0131n dahil edildi\u011fi ve k\u00fclt\u00fcr ile molek\u00fcler y\u00f6ntemlerin birlikte kullan\u0131ld\u0131\u011f\u0131 s\u0131n\u0131rl\u0131 say\u0131da \u00e7al\u0131\u015fma mevcuttur.<\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fmam\u0131zda, ETA \u00f6rneklerinde, m-PCR ile hastalar\u0131n 65 (%87.8)\u2019inde, k\u00fclt\u00fcr ile 43 (%58)\u2019\u00fcnde en az bir etken pozitif saptand\u0131.<span class=\"Apple-converted-space\">\u00a0 <\/span>Gadsby ve arkada\u015flar\u0131n\u0131n (7) yapt\u0131klar\u0131 bir \u00e7al\u0131\u015fmada, TKP hastalar\u0131n\u0131n alt solunum yolu \u00f6rnekleri m-PCR ve k\u00fclt\u00fcr ile de\u011ferlendirilmi\u015f ve PCR ile hastalar\u0131n %87\u2019sinde, k\u00fclt\u00fcr ile %39\u2019unda patojen tespit edilmi\u015ftir. \u00c7al\u0131\u015fmam\u0131zdaki veriler PCR ve k\u00fclt\u00fcr ile etken saptama oranlar\u0131 a\u00e7\u0131s\u0131ndan literat\u00fcrle uyumluydu.<\/p>\n<p class=\"p3\">TKP hastalar\u0131n\u0131n %71.4\u2019\u00fcnde <i>S. pneumoniae <\/i>PCR ile pozitif saptan\u0131rken, sadece bir hastan\u0131n ETA \u00f6rne\u011fi k\u00fclt\u00fcr\u00fcnde ve bir hastan\u0131n kan k\u00fclt\u00fcr\u00fcnde <i>S. pneumoniae<\/i> \u00fcredi. D\u00fcnyada toplum k\u00f6kenli pn\u00f6monilerin yakla\u015f\u0131k %5-%48\u2019inden <i>S. pneumoniae<\/i> sorumludur (8, 9). Alt solunum yolu \u00f6rneklerinde PCR y\u00f6ntemiyle <i>S. pneumoniae<\/i> pozitif saptanma oran\u0131 kullan\u0131lan y\u00f6nteme g\u00f6re %6-%80 aras\u0131nda de\u011fi\u015fmektedir (10-12). <i>S. pneumoniae<\/i> insanda \u00f6zellikle nazofarenkste kolonize olabilen bir patojen oldu\u011fu i\u00e7in PCR pozitifli\u011fi olan bireylerde kolonizasyon-infeksiyon ayr\u0131m\u0131 yapmak olduk\u00e7a g\u00fc\u00e7t\u00fcr. \u00c7al\u0131\u015fmam\u0131zda, pn\u00f6moni etkenlerini belirlemek amac\u0131yla ventilat\u00f6re ba\u011fl\u0131 hastalar\u0131n tamam\u0131nda solunum yolu \u00f6rne\u011fi olarak ETA \u00f6rne\u011fi al\u0131nd\u0131. Bir\u00e7ok \u00e7al\u0131\u015fma nazofarenksten al\u0131nan \u00f6rneklerin alt solunum yolu infeksiyonlar\u0131 i\u00e7in yalanc\u0131 negatiflik ve yalanc\u0131 pozitiflik ile sonu\u00e7lanabilece\u011fini g\u00f6stermi\u015ftir (13-15). Literat\u00fcrde, kolonizasyon\/infeksiyon ayr\u0131m\u0131 i\u00e7in kantitatif PCR metotlar\u0131 daha spesifik bulunmu\u015ftur (16). \u00c7al\u0131\u015fmam\u0131zda y\u00f6ntem olarak kantitatif PCR kullan\u0131lmamas\u0131 nedeni ile <i>S. pneumoniae<\/i>\u2019n\u0131n y\u00fcksek oranda saptand\u0131\u011f\u0131 d\u00fc\u015f\u00fcn\u00fcld\u00fc. Ayr\u0131ca kullan\u0131lan PCR metoduna g\u00f6re di\u011fer streptokok t\u00fcrleri ile \u00e7apraz reaksiyon g\u00f6stererek yalanc\u0131 pozitif sonu\u00e7lar da g\u00f6r\u00fclebilmektedir (17). Bu nedenle sa\u011fl\u0131kl\u0131 ki\u015filerde kolonize olabilen mikroorganizmalar i\u00e7in tan\u0131da daha spesifik olan molek\u00fcler y\u00f6ntemler kullan\u0131lmas\u0131 gerekebili<span class=\"s7\">r.<\/span><\/p>\n<p class=\"p3\">TKP hastalar\u0131nda; <i>S. auerus<\/i> k\u00fclt\u00fcrde<i> <\/i>%17.9 oran\u0131 ile en s\u0131k saptanan etken olup PCR\u2019da %25 oran\u0131 ile ikinci s\u0131rada saptand\u0131. Literat\u00fcrde toplum k\u00f6kenli pn\u00f6moni etyolojisinde <i>S. auerus<\/i> olgular\u0131n %1.6-%10.2\u2019unu olu\u015fturmaktad\u0131r (8, 18). <i>S. auerus<\/i> pn\u00f6monisinin a\u011f\u0131r nekrotizan pn\u00f6moni \u015feklinde seyretme riski y\u00fcksektir; hastalar\u0131n yakla\u015f\u0131k %49-%74\u2019\u00fc mekanik ventilasyon ihtiyac\u0131 g\u00f6stermektedir (19, 20). <span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\"><span class=\"s5\">HKP hastalar\u0131n\u0131n %53.8\u2019inde <i>S. pneumoniae<\/i> PCR testi pozitif saptan\u0131rken hastalar\u0131n hi\u00e7birinin kan ve ETA \u00f6rne\u011fi k\u00fclt\u00fcr\u00fcnde <i>S. pneumoniae<\/i> \u00fcremesi saptanmad\u0131. Literat\u00fcrde HKP etyolojisinde genellikle Gram-negatif enterik basiller \u00f6n planda bildirilmekle birlikte bu \u00e7al\u0131\u015fmalar V\u0130P hastalar\u0131n\u0131 da i\u00e7ermektedir. \u00c7al\u0131\u015fmam\u0131zda, V\u0130P hastalar\u0131 etken farkl\u0131l\u0131klar\u0131n\u0131 saptayabilmek i\u00e7in HKP hasta grubuna dahil edilmedi. Yo\u011fun bak\u0131m d\u0131\u015f\u0131nda takip edilen HKP olgular\u0131nda yap\u0131lan bir ara\u015ft\u0131rmada \u00e7al\u0131\u015fmam\u0131zla benzer \u015fekilde<i> S. pneumoniae <\/i>pn\u00f6moni etkeni olarak ilk s\u0131rada yer alm\u0131\u015ft\u0131r (21).<\/span><\/p>\n<p class=\"p3\">V\u0130P hastalar\u0131n\u0131n ETA \u00f6rneklerinde PCR ile en s\u0131k saptad\u0131\u011f\u0131m\u0131z etkenler s\u0131ras\u0131yla; %54.5 oran\u0131nda <i>K. pneumoniae ve <\/i>%42.4 oran\u0131nda <i>S. pneumoniae\u2019<\/i>dir.<i> <\/i>Hastalar\u0131n ETA \u00f6rne\u011fi k\u00fclt\u00fcrlerinde ise %33.3<i> <\/i>oran\u0131nda<i> Klebsiella <\/i>spp<i>. <\/i>ve<i> <\/i>%15.1 oran\u0131nda<i> Acinetobacter <\/i>spp<i>. <\/i>\u00fcredi.<i> <\/i>\u00dclkemizde yap\u0131lan \u00e7al\u0131\u015fmalarda, V\u0130P etkeni olarak; <i>Acinetobacter baumannii<\/i>, <i>Pseudomonas aeruginosa<\/i>, <i>K. pneumoniae <\/i>ve <i>Enterobacter cloacae<\/i> gibi Gram-negatif bakterilerin \u00f6n planda oldu\u011fu, Gram-pozitif bakterilerde ise en s\u0131k <i>S. aureus<\/i>\u2019un<i> <\/i>izole edildi\u011fi bildirilmi\u015ftir (22-24).<\/p>\n<p class=\"p3\">Literat\u00fcrde TKP hastalar\u0131n\u0131n ortalama %20-%28.6\u2019s\u0131nda atipik etken bildirilmi\u015ftir. Sundu\u011fumuz \u00e7al\u0131\u015fmada da benzer olarak TKP hastalar\u0131n\u0131n %28.5\u2019inde atipik etken saptand\u0131 (25, 26). \u00dclkemizde yap\u0131lan \u00e7al\u0131\u015fmalarda, atipik pn\u00f6moni verileri \u00e7al\u0131\u015fmalar\u0131n yeri ve zaman\u0131na g\u00f6re de\u011fi\u015fmektedir.<span class=\"Apple-converted-space\">\u00a0 <\/span>\u00dclkemizde yap\u0131lan \u00e7al\u0131\u015fmalardan farkl\u0131 olarak hi\u00e7bir hastada <i>M. pneumoniae <\/i>saptamad\u0131k. Bunun nedeni, sadece ventilat\u00f6re ba\u011fl\u0131 hastalar\u0131 \u00e7al\u0131\u015fmaya dahil etmemiz olabilir. Nitekim <i>M. pneumoniae\u2019<\/i>n\u0131n neden oldu\u011fu pn\u00f6moni tablosunun di\u011fer etkenlere k\u0131yasla daha hafif seyretti\u011fi bilinmektedir (27).<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">HKP olgular\u0131n\u0131n %23\u2019\u00fcnde atipik pn\u00f6moni etkeni saptad\u0131k; bunlar\u0131n t\u00fcm\u00fcn\u00fc viral etkenler olu\u015fturmaktayd\u0131. Molek\u00fcler y\u00f6ntemlerin klinik kullan\u0131ma girmesi ile birlikte yap\u0131lan \u00e7al\u0131\u015fmalarda HKP olgular\u0131nda viral etkenlerin saptanma oran\u0131 %5.9- %24.4 olarak bildirilmi\u015ftir (28, 29). HKP\u2019lerde viral pn\u00f6moni etkenlerini saptama oran\u0131m\u0131z literat\u00fcrle uyumluydu.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fmam\u0131zda, m-PCR y\u00f6ntemi ile ETA \u00f6rneklerinde viral etken saptanan hastalar\u0131n %44.4\u2019\u00fcne bakteriyel bir etken de e\u015flik ediyordu. Literat\u00fcrde, molek\u00fcler \u00e7al\u0131\u015fmalarla saptanan virus-bakteri birlikteli\u011fi oran\u0131 %5.3-%81.6 aras\u0131nda geni\u015f bir da\u011f\u0131l\u0131m g\u00f6stermektedir (3, 30). \u00c7al\u0131\u015fmalar aras\u0131ndaki bu farkl\u0131l\u0131k, ara\u015ft\u0131r\u0131lan virus say\u0131s\u0131, mevsimsel \u00f6zellikler ve kullan\u0131lan PCR y\u00f6nteminden kaynaklanabilir.<\/p>\n<p class=\"p3\">HKP olgular\u0131n\u0131n ikisinde influenza virusu saptand\u0131k. Bu nedenle, \u00f6zellikle antibiyotik tedavisine yan\u0131t al\u0131namayan HKP olgular\u0131nda pn\u00f6moni etkeni olarak influenza virusu ak\u0131lda tutulmal\u0131d\u0131r.<\/p>\n<p class=\"p3\">V\u0130P hastalar\u0131n\u0131n hi\u00e7birinde atipik pn\u00f6moni etkeni tespit edilmedi. Ba\u015fta <i>L. pneumophila<\/i> olmak \u00fczere <i>M. pneumoniae<\/i>, herpes simpleks vir\u00fcs\u00fc (HSV) ve sitomegalovirus (CMV) gibi baz\u0131 viruslar\u0131n V\u0130P\u2019te etken olabilece\u011fini g\u00f6steren \u00e7al\u0131\u015fmalar bulunmaktad\u0131r (28, 31, 32). Ancak kulland\u0131\u011f\u0131m\u0131z m-PCR kitinin s\u00f6z konusu viruslar\u0131 kapsamamas\u0131 ve hasta say\u0131m\u0131z\u0131n az olmas\u0131 bu etkenleri saptayamam\u0131\u015f olmam\u0131z\u0131n nedeni olabilir.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">\u0130nceledi\u011fimiz laboratuvar parametrelerinden; WBC, PCT ve NLO de\u011ferlerinin pn\u00f6moni alt t\u00fcrleri aras\u0131nda istatiksel olarak anlaml\u0131 d\u00fczeyde farkl\u0131l\u0131k g\u00f6stermedi\u011fini tespit ettik. CRP de\u011feri V\u0130P hastalar\u0131nda TKP hastalar\u0131na g\u00f6re anlaml\u0131 derece y\u00fcksek bulundu. V\u0130P grubunda hi\u00e7bir hastada viral etken saptanmamas\u0131 da CRP\u2019nin di\u011fer hasta gruplar\u0131na g\u00f6re daha y\u00fcksek \u00e7\u0131kmas\u0131n\u0131 a\u00e7\u0131klayabilir. Ayr\u0131ca CRP\u2019nin Gram-negatif etkene ba\u011fl\u0131 geli\u015fen nozokomiyal bakteriyemik olgularda Gram-pozitif etkene ba\u011fl\u0131 geli\u015fen bakteriyemik olgulara g\u00f6re daha y\u00fcksek seyretti\u011fini g\u00f6steren \u00e7al\u0131\u015fmalar bulunmaktad\u0131r (33). Bu durum Gram-negatif patojenlerin daha s\u0131k saptand\u0131\u011f\u0131 V\u0130P hasta grubunda, e\u015flik eden bakteriyemi nedeni ile CRP de\u011ferlerinin di\u011fer pn\u00f6moni gruplar\u0131na g\u00f6re daha y\u00fcksek seyretmesini a\u00e7\u0131klayabilir.<\/p>\n<p class=\"p3\">Tipik pn\u00f6moni etkenleri ve atipik pn\u00f6moni etkenleri saptanan hastalar\u0131n PCT<i> <\/i>de\u011ferleri kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda; tipik etkenlerle infekte hastalar\u0131n ortanca de\u011feri 0.7 (0.07-100) iken atipik etkenle infekte hastalarda bu de\u011fer 12.9 (0.40-58.0) olarak bulundu (<i>p<\/i>=0.002). Literat\u00fcrde atipik pn\u00f6monilerde tipik pn\u00f6monilere g\u00f6re daha d\u00fc\u015f\u00fck PCT de\u011ferleri bildirilmi\u015ftir (34). Atipik etkenlerin viral etkenleri de kapsad\u0131\u011f\u0131 d\u00fc\u015f\u00fcn\u00fclerek \u00e7al\u0131\u015fmam\u0131zda bu beklenmeyen y\u00fcksek de\u011ferlerin nedeninin ba\u015fta influenza tan\u0131s\u0131 olan hastalar olmak \u00fczere atipik etken saptanan hastalardaki bakteriyel ko-infeksiyona ba\u011fl\u0131 olabilece\u011fi d\u00fc\u015f\u00fcn\u00fcld\u00fc.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\"><span class=\"s5\">\u00c7al\u0131\u015fmam\u0131zda atipik pn\u00f6moni etkenlerinin saptand\u0131\u011f\u0131 hastalar\u0131n ya\u015f ortanca de\u011feri 58 ya\u015f, tipik pn\u00f6moni hastalar\u0131n ya\u015f ortanca de\u011feri ise 69 ya\u015ft\u0131. \u0130ki grup aras\u0131nda ya\u015f a\u00e7\u0131s\u0131ndan istatiksel olarak anlaml\u0131 d\u00fczeyde farkl\u0131l\u0131k saptanmamakla birlikte atipik pn\u00f6moni grubunun daha gen\u00e7 ya\u015fta oldu\u011fu g\u00f6r\u00fcld\u00fc (<i>p<\/i>=0.15). Atipik pn\u00f6moni etkenlerinin, gen\u00e7 ya\u015flarda daha s\u0131k g\u00f6r\u00fcld\u00fc\u011f\u00fc bildirilmesine ra\u011fmen, \u00f6zellikle ileri ya\u015f grubunda da atipik pn\u00f6moni etkenlerinin s\u0131k g\u00f6r\u00fclebilece\u011fi rapor edilmi\u015ftir (35).<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p3\">Ventilat\u00f6r deste\u011fi gerektiren a\u011f\u0131r seyirli pn\u00f6monili hastalar\u0131n de\u011ferlendirildi\u011fi \u00e7al\u0131\u015fmam\u0131zda, gen\u00e7 ya\u015f grubunda mekanik ventilasyon gerektirecek a\u011f\u0131r klinik tabloyla kar\u015f\u0131la\u015f\u0131lmas\u0131 durumunda, \u00f6zellikle <i>L. pneumophila <\/i>ve influenza<i> <\/i>ba\u015fta olmak \u00fczere atipik pn\u00f6moni etkenlerin ara\u015ft\u0131r\u0131lmas\u0131n\u0131n yararl\u0131 olaca\u011f\u0131 g\u00f6r\u00fc\u015f\u00fcndeyiz.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fmam\u0131z\u0131n en \u00f6nemli k\u0131s\u0131tl\u0131l\u0131\u011f\u0131 pandemi nedeni ile istenilen hasta say\u0131s\u0131na ula\u015f\u0131lamam\u0131\u015f olmas\u0131d\u0131r.<span class=\"Apple-converted-space\">\u00a0 <\/span>\u00c7al\u0131\u015f\u0131lan m-PCR kitinde <i>Chlamydia<\/i> t\u00fcrlerinin bulunmamas\u0131 etken oranlar\u0131m\u0131z\u0131 de\u011fi\u015ftirmi\u015f olabilir. Kullan\u0131lan y\u00f6ntemin kantitatif olmamas\u0131 nedeniyle \u00f6zellikle <i>S. pneumoniae <\/i>i\u00e7in kolonizasyon\/infeksiyon ayr\u0131m\u0131 yapmam\u0131z m\u00fcmk\u00fcn olmad\u0131. ETA \u00f6rneklerinin t\u00fcm\u00fc antibiyotik tedavisi \u00f6ncesi al\u0131namad\u0131\u011f\u0131 i\u00e7in PCR ve k\u00fclt\u00fcr ile etken belirleme oranlar\u0131n\u0131n k\u0131yaslanmas\u0131 do\u011fru sonu\u00e7lar vermemi\u015f olabilir. Bununla birlikte, \u00e7al\u0131\u015fmam\u0131z a\u011f\u0131r seyirli pn\u00f6moni hastalar\u0131n\u0131n ETA \u00f6rneklerinde m-PCR y\u00f6ntemi ile atipik etkenlerin ara\u015ft\u0131r\u0131ld\u0131\u011f\u0131 az say\u0131daki \u00e7al\u0131\u015fmadan biri olmas\u0131 y\u00f6n\u00fcyle \u00f6nemlidir.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">Sonu\u00e7 olarak; pn\u00f6moni hastalar\u0131n\u0131n solunum \u00f6rneklerinde konvansiyonel y\u00f6ntemler d\u0131\u015f\u0131nda molek\u00fcler y\u00f6ntemlerle de etkenlerin belirlenmesi pn\u00f6moni tedavi protokollerine \u00f6nemli katk\u0131 sa\u011flayacakt\u0131r.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>G\u0130R\u0130\u015e Pn\u00f6moniler, t\u00fcm d\u00fcnyada ciddi bir morbidite ve mortalite sebebidir. Koronavirus hastal\u0131\u011f\u0131 2019 (COVID-19) pandemisi gibi d\u00fcnya genelinde meydana gelen salg\u0131nlar, pn\u00f6moni patogenezini anlaman\u0131n, tedavinin ve \u00f6nlem protokolleri olu\u015fturman\u0131n \u00f6nemini ortaya koymaktad\u0131r. A\u015f\u0131lama programlar\u0131 ile bir\u00e7ok geli\u015fmi\u015f \u00fclkede toplum k\u00f6kenli pn\u00f6mokok ve Haemophilus influenzae\u00a0tip b pn\u00f6monisi oranlar\u0131nda d\u00fc\u015f\u00fc\u015f kaydedilmekle birlikte \u00f6zellikle diren\u00e7li Gram-negatif bakterilere ba\u011fl\u0131 [&hellip;]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[3394,5506,5507,3007],"class_list":["post-25450","post","type-post","status-publish","format-standard","hentry","category-ozgun-arastirma","tag-endotrakeal-aspirat","tag-konvansiyonel-yontemler","tag-multipleks-pcr","tag-pnomoni"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25450","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=25450"}],"version-history":[{"count":3,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25450\/revisions"}],"predecessor-version":[{"id":25538,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25450\/revisions\/25538"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=25450"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=25450"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=25450"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}