대한요로생식기감염학회지 : 제 6 권제 2 호 2011년 10월 Korean J UTII Vol. 6, No. 2, October 2011 원저 급성세균성전립선염의임상경과에관한다기관연구 이화여자대학교의과대학, 1 가톨릭대학교의과대학, 2 국립경찰병원, 3 경희대학교의과대학, 4 서울대학교의과대학, 5 순천향대학교의과대학, 6 아주대학교의과대학, 7 중앙대학교의과대학, 8 건국대학교의과대학, 9 단국대학교의과대학, 10 충남대학교의과대학, 11 한림대학교의과대학, 12 원광대학교의과대학, 13 전남대학교의과대학, 14 조선대학교의과대학, 15 고신대학교의과대학, 16 동국대학교의과대학, 17 동아대학교의과대학, 18 인제대학교의과대학, 19 부산대학교의과대학비뇨기과학교실 이성주 구진모 심봉석 조용현 1 한창희 1 민승기 2 이선주 3 손환철 4 김준모 5 최종보 6 김태형 7 양상국 8 이길호 9 나용길 10 이성호 11 정희종 12 정승일 13 김철성 14 정재민 15 서영진 16 조원열 17 민권식 18 이상돈 19 [Abstract] Clinical Outcome of Acute Bacterial Prostatitis; A Multicenter Study Seong Ju Lee, Jin Mo Koo, Bong Suk Shim, Yong Hyun Cho 1, Chang Hee Han 1, Seung Ki Min 2, Sung Joo Lee 3, Hwan Cheol Son 4, Jun Mo Kim 5, Jong Bo Choi 6, Tae Hyoung Kim 7, Sang Kuk Yang 8, Kil Ho Lee 9, Yong Kil Na 10, Sung Ho Lee 11, Hee Jong Jung 12, Seung Il Jung 13, Chul Sung Kim 14, Jae Min Chung 15, Young Jin Seo 16, Won Yeol Cho 17, Kweon Sik Min 18, Sang Don Lee 19 From the Department of Urology, Ewha University, 1 Catholic University, 2 National Police Hospital, 3 Kyung Hee University, 4 Seoul National University, 5 Soonchunhyang University, 6 Ajou University, 7 Chungang University, 8 Konkuk University, 9 Dankuk University, 10 Chungnam National University, 11 Hallym University, 12 Wonkwang University, 13 Chonnam National University, 14 Chosun University, 15 Kosin University, 16 Dongguk University, 17 Dong-A University, 18 Inje University, 19 Pusan National University Purpose: Proper guidelines concerning antibiotic administration for acute bacterial prostatitis (ABP) are unclear. We retrospectively analyzed treatment status and clinical outcomes to establish a proper treatment guideline. 교신저자 : 심봉석, 이화여자대학교의학전문대학원비뇨기과학교실서울시양천구목동 911-1 우 158-710 Tel: 02-2650-5157, Fax: 02-2654-3682, E-mail: bonstone@ewha.ac.kr Received: August 9, 2011 Revised: September 7, 2011 Accepted: September 16, 2011 165
166 대한요로생식기감염학회지 : 제 6 권제 2 호 2011 년 10 월 Materials and Methods: The clinical records of 669 patients from 21 hospitals diagnosed with ABP were reviewed. Prior manipulation, antibiotics administration, mean length of treatment, complication and procedure were analyzed. Results: The mean age of 538 patients (80.4%) without manipulation (group 1) and 131 patients (19.6%) with manipulation (group 2) was 58.3 years (range 19-88 years). Transrectal prostate biopsy was the most common cause of acute bacterial prostatitis (n=66; 50.4%). Of the clinical symptoms in the non-manipulation and manipulation groups, fever was most common (88.2% and 86.3%, respectively). Acute urinary retention (14.3% and 28.1%, respectively) was significantly increased in the manipulation group (p<0.05). Escherichia coli was the most frequently isolated bacterium from urine (72.0% and 66.7% of cases, respectively). Mean length of treatment was 6.5days and 7.9days, respectively; the difference was significant (p<0.05). Combination antibiotic therapy with third generation cephalosporin+aminoglycoside was used in 49.3% and 55.5% of cases, respectively. For single antibiotic therapy, second generation quinolones were used the most (35.5% and 34.3%, respectively). Sequale occurred in 29 group 1 patients (5.4%) and 20 group 2 patients (15.3%); the difference was significant (p<0.05). Conclusions: Prior manipulation was associated with 20% of ABP patients. Regardless of manipulation, clinical outcome was similar after treating with appropriate antibiotics. (Korean J UTII 2011;6:165-170) Key Words: Anti-bacterial agents, Prostatitis, Treatment, Outcome 서 론 대상및방법 열성요로감염질환인급성전립선염은실제전립선의감염상태를직접확인하기어려워임상증상에따라진단되어치료방식이결정된다. 1 이는전립선염의 5% 정도를차지하고치료하지않으면패혈증같은치명적인결과까지초래할수있으나대부분어렵지않게치료할수있다. 2-4 현재는전신증상이있으면항생제경정맥투여로치료를시작하고이후경구용항생제로전환한다. 5 보통항생제는 2-4주간투여하지만아직까지투여방법및기간에대한지침이정립되지않은상태이다. 6 이에저자들은술기여부에따른치료를비교하였고급성전립선염은발병률이낮기에다기관연구를통한치료실태및임상경과를파악하고향후치료지침을위한기초자료로삼고자하였다. 2007년 1월부터 2009년 12월까지전국 21개종합병원을대상으로급성전립선염으로치료받은환자 669명의의무기록을후향적으로조사하였다. 급성전립선염은임상증상 ( 발열, 하부요로증상 ) 과혈액검사결과 ( 백혈구증가증 ) 를토대로진단하였다. 증상과요배양검사양성인경우환자군에포함시켰고증상은있으나이전항생제치료에의한요배양검사음성인경우는제외시켰다. 또한급성전립선염과직접적연관이없는만성질환 ( 고혈압, 당뇨 ) 이있는경우포함시켰고다른열성요로감염 ( 신우신염, 고환염 ) 이동반된경우는제외시켰다. 발병전비뇨기과적술기여부에따라두군으로나누어그에따른임상증상, 배양균, 투여항생제종류와기간, 합병증및처치등을조사하였다. 통계학적검증은 chi-square test, Student's t-test를이용하였으며, p 값이 0.05 미만일때통계학적으로유의한것으로판정하였다.
이성주외 : 급성세균성전립선염의임상경과에관한다기관연구 167 결과비처치군 538명 (80.4%), 처치군 131명 (19.6%) 으로평균연령은 58.3 (19-88) 세였고 60대가 138명 (25.7%) 으로가장많았으나두군간연령에따른유의성은보이지않았다 (p<0.05) (Fig. 1). 처치는전립선조직검사가 66명 (50.4%) 으로가장많았다 (Table 1). 임상증상은두군모두발열이 88.2%, 86.3% 로가장흔했으며, 급성요폐가 14.3%, 28.1% 로처치군에서유의하게많았다 (p<0.05) (Table 2). 배양균은두군모두대장균이 72.0%, 66.7% 로가장많았고녹농균은 4.9%, 11.6% 로처치군에서유의하게높은비율을보였다 (p<0.05) (Table 3). 입 원치료는각각 109명 (20.3%), 128명 (97.7%) 이었고치료기간은 6.5일, 7.9일로처치군에서유의하게길었다 (p<0.05) (Fig. 2). 항생제처방은 3 rd cephalosporin과 aminoglycoside 병합처방이 49.3%, 55.5% 였고단독처방은 2 nd quinolones이 35.5%, 34.3% 로가장많았다 (Table 4). 후유증으로는농양이 29명 (5.4%), 20명 (15.3%) 로처치군에서유의하게많았고 (p<0.05) 그에따른치료로비처치군에서경요도배농, 회음부흡입, 약물치료순으로 14명 (48.3%), 8 명 (27.6%), 7명 (24.1%) 이시행되었고, 처치군에서 8명 (40%), 9명 (45.0%), 3명 (15.0%) 이시행되었다 (Table 5). 200 150 100 50 0 with manipulation without manipulation -19 20-29 30-39 40-49 50-59 60-69 70- Age Fig. 1. Age distibution in patients with acute bacterial prostatitis according to with or without manipulation. Table 1. Prior manipulation in patients with acute bacterial prostatitis No. patients (%) Without manipulation 538 (80.4) With manipulation 131 (19.6) Prostate biopsy 66 (50.4) Foley catheterization 26 (19.8) Operation via urethra 11 ( 8.4) Cystoscopy 10 ( 7.6) Urodynamic study 9 ( 6.9) Digital rectal examination 4 ( 3.1) Others 5 ( 3.8) Table 2. Comparison of clinical symptoms between manipulation group and no manipulation group in patients with acute bacterial prostatitis Without manipulation (%) With manipulation (%) p-value a Fever 88.2 86.3 0.807 Pain, any kinds 31.0 29.8 0.506 Dysuria 48.3 44.3 0.143 Urinary retention 14.3 28.1 0.020 Voiding symptoms 48.0 38.9 0.212 Storage symptoms 39.6 33.6 0.137 a : chi-square test
168 대한요로생식기감염학회지 : 제 6 권제 2 호 2011 년 10 월 Table 3. Microbiological spectrum according to urine culture in patients with acute bacterial prostatitis Without manipulation (%) With manipulation (%) Total (%) Negative 356 (66.2) 62 (47.3) 418 (62.5) Positive 182 (33.8) 69 (52.7) 251 (37.5) E. coli 72.0 66.7 70.5 K. pneumoniae 8.8 7.2 8.4 P. aeruginosa 4.9 11.6 6.8 E. faecalis 4.9 7.2 5.6 S. aureus 3.8 5.8 4.4 Proteus 1.6 1.4 1.6 Table 4. Distribution of prescribed antimicrobial agents in patients with acute bacterial prostatitis Antimicrobial agent Without manipulation (%) With manipulation (%) Single therapy Penicillins 9.3 8.6 1 st cephalosporins 0.9 0.0 2 nd cephalosporins 24.3 11.4 3 rd cephalosporins 17.8 31.4 2 nd quinolones 35.5 34.3 3 rd quinolones 6.5 11.4 etc 5.6 2.9 Combination therapy Penicillin+aminoglycoside 1.5 1.6 1 st cephalosporin+aminoglycoside 5.5 4.1 2 nd cephalosporin+aminoglycoside 27.4 29.9 3 rd cephalosporin+aminoglycoside 49.3 55.5 1 st cephalosporin+quinolone 1.7 0.0 2 nd cephalosporin+quinolone 6.8 2.0 3 rd cephalosporins+quinolone 4.1 4.9 Quinolone+aminoglycoside 1.7 2.0 고찰전립선염의분류에서급성전립선염은 5% 미만으로비뇨기적으로드문질환이지만갑작스런고열과오한, 하부요통, 회음부통증, 빈뇨, 요급박, 야간뇨, 배뇨통및배뇨곤란등하부요로증상을보이고근육통, 관절통의증상이나타나므로임상증상으로진단이가능하고치료가잘되는것으로알려져있 다. 7-9 본연구에서도고열이주증상이었고, 증상발현후대부분 3일이내에외래나응급실을경유하여입원하였으며, 평균 7일이내에퇴원하였다. 10 요검사에서대부분농뇨소견을보이는데본연구에서도 80% 로나타났으며일반균배양검사양성률은 37% 로기존연구들에비해약간낮은수치를보였다. 11 원인균은 80% 가 E. coli로알려져있는데, 12,13 본연구에서도 E. coli가가장흔한균으로나타났다. 균배양검사양성률이기존에비해낮게나타난것
이성주외 : 급성세균성전립선염의임상경과에관한다기관연구 169 Table 5. Formation incidence and management of prostatic abscess Prostatic abscess Without manipulation (%) With manipulation (%) p-value Formation incidence 29 (5.4) 20 (15.3) 0.032 a Management Medical therapy 7 (24.1) 3 (15.0) Perineal aspiration 8 (27.6) 9 (45.0) Transurethral drainage 14 (48.3) 8 (40.0) a : Student s t-test 25 20 15 10 5 0 admission after admission out-patient manipulation (-) manipulation (+) Fig. 2. Mean length of antibiotics therapy in patients with acute bacterial prostatitis according to with or without manipulation. 은환자군선정과정에서항생제복용후치료된경우가완전히배제되지않음에따른것으로생각한다. 급성전립선염의모든환자에서초음파검사가필요하지는않지만전립선농양이형성되었는지를알아보는데유용하다. 급성전립선염에서항생제요법은간단하고도효과적이어서대부분의환자에서 48 시간이내에초음파검사로전립선농양이형성되지는않았는지확인하여야한다. 14,15 급성전립선염에서농양이형성되는경우가 7% 정도로보고되는데, 16 본연구에서는술기를시행하지않은군과시행한군에서각각 5%, 15% 정도로나타난것으로보아비뇨기과적술기여부가합병증에영향을미치는것으로생각한다. 이의치료로는경요도적절개술에의한배농을통해좋은경과를볼수있었다. 급성전립선염의일반적치료는소변과혈액의배양검체를얻은후즉시경험적항생제치료를시도하여야하는데이경우전립선마사지는환자의극심한고통및패혈증의유발가능성때문에금기이다. 17 치료항생제로는광범위한항균력을가진 3 세대 cepha 계열을 aminoglycoside와병용하여사용할수있고 quinolone을단독으로사용할수도있다. 18 저자들은일반적치료에따라입원기간동안에는 3세대 cepha계약물과 aminoglycoside 경정맥투여의복합치료를하였고외래치료의경우 quinolone 단독치료를통해좋은경과를볼수있었다. 비뇨기과적술기는급성전립선염의원인이될수있는데그중에서전립선조직생검과요도카테터유치가가장흔하다. 19 침습적술기들은감염균의임프구성혹은혈행성전파를야기할수있고최근증가하는이런술기에대비하여철저한예방이필요할것으로생각한다. 그러기위해예방적항생제투여를하고술기후증상관찰을통하여합병증발생을막아야한다. 본연구에서급성전립선염을일으킬수있는술기의종류에따른임상경과의차이를비교하지못한부분은보완해야할부분이라고생각한다. 그러나이미알려진바와같이경험적항생제투여에의한효과적인치료가국내에서많이이루어지고있었고좋은경과도볼수있었다. 결론많은경우술기여부에따른임상경과가차이가없는것으로나타났고급성세균성전립선염의 20% 에서만사전술기와관련이있었다. 급성전립선염
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