한국임상약학회지제 23 권제 1 호 Kor. J. Clin. Pharm., Vol. 23, No. 1. 2013 화상감염소아환자에서분리된주요균종에대한항생제의내성률 강주연 신혜순 * 덕성여자대학교약학대학 (2012 년 12 월 28 일접수 2013 년 3 월 2 일수정 2013 년 3 월 4 일승인 ) Antimicrobial Resistance of Clinically Important Bacteria Isolated from Burn Wound Infections in Children Joo Yeon Kang and Hea Soon Shin* College of Pharmacy, Duksung Women s University, Seoul 132-714, Korea (Received December 28, 2012 Revised March 2, 2013 Accepted March 4, 2013) Background & Objectives: Burn injury mortality and septic complication are frequent and well-known in burned pediatric patients. The overuse of antibiotics is the base for development of wound infection by resistant microorganisms as well as opportunist agents. Methods: We have carried out a study of the bacterial profile and antimicrobial resistance clinically important bacteria isolated from burn wound infections in children patients. The most common isolate from burn wound cultures was Pseudomonas aeruginosa (26.8%), followed by Staphylococcus aureus (25.4%), Acinetobacter baumannii (12.7%), coagulase negative staphylococcus (12.0%), Enterococcus faecium (7.7%), Escherichia coli (4.9%), Enterococcus faecalis (3.7%), Burkholderia cepacia (3.0%), Enterobacter cloacae (2.3%) and Klebsiella pneumonia (2.3%). Colistin was very significantly effective drug in gram negative organism, such as Pseudomonas aeruginosa and Acinetobacter baumannii. Results & Conclusion: The resistance rates were 65% and 98% to piperacillin, 63% and 97% to ceftazidime, 28% and 50% to levofloxacin. The most effective antibiotic in gram positive organism, such as Staphylococcus aureus, coagulase negative staphylococcus were moxifloxacin. The resistance rates were 83% and 64% to ciprofloxacin, 80% and 17% to clindamycin. Key words - antibiotic resistance, burn wound infection, Pseudomonas aeruginosa, Staphylococcus aureus, Acinetobacter baumannii 화상에서창상감염은흔히발생하는증상인데, 1-3) 화상을입은초기에는대부분의피부상재균이소멸하여세균감염이없으나 48시간내에호흡기상재균인그람양성세균이화상부위에집락을형성하게되고, 수일후에는그람음성세균에의한감염이일어난다. 2, 4-5) Lawrence 6) 등의연구에의하면 Staphylococcus와같은그람양성구균은입원 2~6일이내에, Psudomonas aeruginosa 등의그람음성간균들은 10~15일후에분리되기시작한다고한다. 면역기능이저하되어국소적인감염에서전신적인감염으로확대되는데, 피부의정상적인방어기능이파괴되고, 면역글로불린과보체감소, 면역세포 helper T-cell 수의감소와 suppressor T-cell 수의증가, interleukin-2 생성감소, 호중구의기능장애등이발생하여세균증식이잘되어높은밀도의균이존재하게되고, 인접한 Correspondence to : Hea Soon Shin College of Pharmacy Duksung Women s University Seoul 132-714, Korea Tel: +82-2-901-8398, Fax: +82-2-901-8386 E-mail: hsshin@duksung.ac.kr 조직에침입하여감염을일으키게된다. 6-7) 화상환자중에는 15세이하의소아가 30~40% 를차지한다고보고된바 5,8,10) 있으며소아화상은뜨거운물에의한열탕화상이가장많다. 소아들은피부의두께가얇아같은온도에의해서도더깊게손상을입고적은범위의화상으로도수분과전해질소실이쉽게발생하며면역기능도상대적으로약해화상으로인한폐렴, 패혈증등합병증으로의발생빈도가성인의경우보다높은것으로위험성은잘알려져있다. 6,8-10) 화상창상감염환자에게는 Pseudomonas aeruginosa, Staphylococcus aureus, Acinetobacter baumannii 등균들이빠르게집락을형성하고증식하게된다. 1,2,7,9) 이러한흔한합병증으로유발될수있는패혈증을일으키는균에대해감수성을보이는항생제를사용하여야하며, 패혈증의예방과치료를위해그리고 2차감염이일어나지않을만큼의기간동안의제한적으로사용하게된다. 11,12) 항균제를사용함에있어서도제3세대 cephalosporin계등과같은다양한광범위항균제가증가함에따라내성균주들도증가하고있는추세이다. 13) 최근에는화상환자의전신적항생제의과도한사용 20
화상감염소아환자에서분리된주요균종에대한항생제의내성률 21 으로내성을갖는균들이증가하여과거에보고된항생제내성결과를치료에적용하기힘들게되었다. 5,14-17) 따라서소아화상환자에서도창상감염을유발하는주요균종을분리해내어각균종별항균제내성률을파악하는것이치료기간을단축할수있는적합한항균제의선택에매우중요한조건이된다고하겠다. 18-21) 이에저자들은 2008년부터 2010년까지 3년간화상감염소아환자들을대상으로하여감염세균및항생제내성률을조사해보고자본연구를진행하였다. 연구방법 화상부위의세균배양서울소재 A 대학병원 (3차진료기관 ) 2008년부터 6월부터 2010년 6월까지의소아청소년과화상환자의임상검체로부터분리한주요균주를배양하여항균제내성률을조사하였다. Staphylococcus 균주의분리용선택배지로는 Staphylococcus Medium No. 110 (Difco, USA) 를사용하였으며최소발육억제농도 (minimal inhibitory concentration, MIC) 측정용배지로는 Mueller Hinton Broth (Difco, USA) 배지를사용하였다. faeclis 등의균주에대하여도 ciprofloxacin, erythromycin, norfloxacin, penicilin-g, trimethoprime + sulfa 등으로검사하였다. 통계적분석사용한통계프로그램으로 IBM SPSS Statistics (Statistical package for social science, SPSS Inc. Chicago, IL, USA) 를이용하여 Chi-square test를시행하였으며, 이중의미가있는인자는다중로지스틱회귀분석을실시하였고, P value가 0.05미만인경우에유의한것으로판정하였다. 연구결과 화상창상감염부위에서분리한세균배양검사 567 건중 항생제감수성시험항균제감수성시험은 National Committee for Clinical Laboratory Standards (NCCLS) 의기준에따라 22) 디스크확산법을실시하였다. 균을한천평판희석법으로 Mueller Hinton 배지에서배양한 Pseudomonas aeruginosa를비롯하여 Acinetobacter baumannii, Escherichia coli, Burkholderia cepacia, Entertobacter cloacea, Klebsiella pneumonia 균주에대하여는 amikacin, aztreonam, cefepime, cefotaxime, ceftazidime, ciprofloxacin, colistin, gentamicin, imipenem, levofloxacin, piperacillin + tazobactam, ticarcillin+clavulanic acid 등으로검사하였다. 또한 Staphylococcus aureus를비롯하여 Coagulase negative Staphylococcus, Enterococcus faecium, Enterococcus Fig. 1. The identified microorganisms from burn wound infection in children. PA; Pseudomonas aeruginosa, STA; Staphylococcus aureus, ABA; Acinetobacter baumannii, CNS; Coagulase negative Staphylococcus, EFC; Enterococcus faecium, ECO; Escherichia coli, EFA; Enterococcus faeclis, BCE; Burkholderia cepacia, ECL; Entertobacter cloacea, KPN; Klebsiella pneumonia Fig. 2. Comparison of clinical important bacteria isolated from pediatric burn patients from 2008 to 2010. PA; Pseudomonas aeruginosa, STA; Staphylococcus aureus, ABA; Acinetobacter baumannii, CNS; Coagulase negative Staphylococcus, EFC; Enterococcus faecium, ECO; Escherichia coli, EFA; Enterococcus faeclis, BCE; Burkholderia cepacia, ECL; Entertobacter cloacea, KPN; Klebsiella pneumonia
22 Kor. J. Clin. Pharm., Vol. 22, No. 4, 2012 화상창상감염 109건인 19.4% 가중복감염이었다. 화상의초기수일동안은주로화상을입기전에피부에존재하던그람양성균에의한감염이주로많이발생하였고, 창상감염이가장많이생기는시기는화상후첫일주일이었다. 화상부위의분리배양된세균별로보면본연구에서가장많이검출된균주순으로나열하면, Pseudomonas aeruginosa가 26.8%, Staphylococcus aureus가 25.4%, Acinetobacter baumannii 가 12.7%, coagulase negative staphylococcus가 12.0%, Enterococcus faecium이 7.7%, Escherichia coli가 4.9%, Enterococcus faecalis가 3.7%, Burkholderia cepacia가 3.0%, Enterobacter cloacae가 2.3% 그리고 Klebsiella pneumonia가 2.3% 결과로검출되었다 (Fig. 1). 화상감염의균종별분리율은일반적으로 1950년대에는 β- 용혈성연쇄상구균이, 60-70년대에는 P. aeruginosa의분리가가장많았고, 80-90년대에는 P. aeruginosa는감소하는추세이고, S. aureus의분리는증가추세라고보고되었다. 19) 그러나본연구결과로는화상부위의세균배양결과를연도별로 비교하면그람양성균은 Staphylococcus aureus는 2008년 23.7% 에서 2009년 36.8% 로분리율이증가되었고, coagulase negative staphylococcus는 2008년 28.9% 에서 2009년 7.9% 로 2009년부터감소추세이며, Enterococcus faecium은 2009년 10.5% 에서 2010년 2.6% 로 2010년에감소하였다. Pseudomonas aeruginosa는 2008년 40% 에서 2010년 31% 로가장많은분리율을보였으나감소추세를나타내어다른보고들과도일치하였다. Acinetobacter baumannii가 2009년 10.5% 에서 2010년 2.6% 로소폭증가하였으며이외의그람음성균들은조금씩지속적으로감소하여 2010년에는미미한분리율을보였다 (Fig. 2). 항생제감수성시험결과에서 Pseudomonas aeruginosa는 colistin에민감한감수성을나타내었고, trimethoprim + sulfa Fig. 5. Antimicrobial resistance (%) of Acinetobacter baumannii Fig. 3. Antimicrobial resistance (%) of Pseudomonas aeruginosa Fig. 4. Antimicrobial resistance (%) of Staphylococcus aureus Fig. 6. Antimicrobial resistance (%) of Coagulase negative Staphylococcus
화상감염소아환자에서분리된주요균종에대한항생제의내성률 23 Fig. 7. Antimicrobial resistance (%) of Enterococcus faecium 병용요법에강력한내성률을보였다 (Fig. 3). Acinetobacter baumannii도역시 colistin에민감한감수성을나타내었고 (Fig. 5), 대다수항균제에강한내성률을보였다. 이들은각각 piperacillin에 65% 와 98% 결과로내성률을나타내었고, ceftazidime에 63% 와 97% 결과로내성률을보였으며, levofloxacin에는 28% 와 50% 로내성률을나타내었다. Staphylococcus aureus는 penicillin-g에강한내성률을보였고 moxifloxacin에감수성을보였으며 (Fig. 4), coagulase negative staphylococcus 는 moxifloxacin과 clindamycin에감수성을확인하였으며, penicillin-g에강한내성률을나타내었다 (Fig. 6). 이들은각각 ciprofloxacin에 83% 와 64% 로내성률을나타내었고, clindamycin 에는 80% 와 17% 의결과로내성률을보였다. Enterococcus faecium은전반적인항생제내성률을보였다 (Fig. 7). 고찰및결론 2008년부터 6월부터 2010년 6월까지서울소재 A 대학병원소아청소년과화상환자로부터화상부위의세균배양검사결과양성으로나타난 193명을대상으로 567건의창상감염에대하여감염세균및항생제내성률을알아보고자조사하여다음과같은결과를얻었다. 화상부위의세균배양 567건중 109검체 (19.4%) 에서두종류이상의균주가중복검출되었다. 주요임상균주는많이분리된순서로 Pseudomonas aeruginosa, Staphylococcus aureus, Acinetobacter baumannii, coagulase negative staphylococcus, Enterococcus faecium 등이검출되었다. 연구마다경미한정도로상이하나화상환자에게서가장흔히분리되는균주는 Pseudomonas였으며, Bernal 23) 등에의하면 Acinetobacter baumannii, Pseudomonas aeruginosa, Enterococcus faecalis의순서로검출되었다고보고하였다. Ozumba 3) 등에의하면 Klebsiella spp., Staphylococcus aureus, Pseudomonas aeruginosa의순서로, Mousa 5) 의보고에따르면 Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella spp. 의순으로검출되었다고보고되었다. 이렇듯화상감염균의분리율은나라마다다양하여영국이나미국등은 Staphylococcus aureus가보다흔한것으로보고된다. 24) 화상부위의세균배양결과를연도별로비교하면그람양성균은 Staphylococcus aureus는분리율이 2008년에비해증가되었고 coagulase negative staphylococcus는 2009년부터감소추세이며 Enterococcus faecium은 2010년에는감소하였다. Pseudomonas aeruginosa는지속적으로최고분리율을보였으나, 90년대들어서는 P. aeruginosa는감소하는추세이고, S. aureus의분리가증가추세라는다른보고와도일치한다. 20,21) 한편, Acinetobacter baumannii가본연구결과에서는 2008년에비해소폭으로증가하였으며이외에분리되었던그람음성균들은조금씩지속적으로감소하여 2010년에는미미한분리율을보였다. 항생제감수성시험결과에서 Pseudomonas aeruginosa는 colistin에민감한감수성을나타내었고, trimethoprim + sulfa 병용요법에강력한내성률을보였다. Acinetobacter baumannii 도역시 colistin에민감한감수성을나타내었고, 대다수항균제에강한내성률을보였다. Piperacillin과 ceftazidime에대하여 Acinetobacter baumannii가보다강한내성률을보였다. Staphylococcus aureus는 penicillin-g에강한내성률을보였고 moxifloxacin에감수성을보였으며, coagulase negative staphylococcus는 moxifloxacin과 clindamycin에감수성을보였으며, penicillin-g에강한내성률을나타내었다. Ciprofloxacin 과 clindamycin에대하여예상했던대로 Staphylococcus aureus가강한내성률을보였다. Enterococcus faecium은전반적인항생제내성률을보유하였다. Revathi 2) 등에의하면 Pseudomonas aeruginosa은 ceftazidime 과 cefoperazone에는 81.9% 의감수성을보인다고하였으나, 본연구에서는각각 43% 와 41% 의결과로서감수성이높지않았다. 반면에 cefepime이나 aztreonam에는비교적강한감수성을보였다. Rosanova 9) 의보고에따르면, 소아화상감염환자에서 Pseudomonas aeruginosa나 Acinetobacter baumannii 같은그람음성균에 colistin 투여시합병증이증가하지않고감수성이높았다고하였는바본연구에서도현저하게민감한결과로우수한치료제가되었으나신독성등부작용이알려져있다. 19) Pseudomonas aeruginosa 항생제내성률에대하여 Obritsch 25) 등은 2002년미국에서점차증가하고있다고보고하였으며, Raja 26) 등은 2007년영국에서는전반적으로내성률이낮은것으로보고하고있어국내병원뿐아니라국가간차이가있음을확인하였다. 27) 소아화상환자에서도창상감염
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