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Original Article ISSN 975745(Print) / ISSN: 886X(Online) Korean J Urogenit Tract Infect Inflamm ;8():9 방광결석환자에서요로감염균주의특징 김섬, 김성대, 박경기, 김영주, 김현주, 허정식 제주대학교의학전문대학원비뇨기과학교실, 가정의학과교실 Characteristics of Uropathogens in Patients with Bladder Stones Sum Kim, Sung Dae Kim, Kyung Kgi Park, YoungJoo Kim, Hyeon Ju Kim, JungSik Huh Departments of Urology and Family Medicine, Jeju National University Graduate School of Medicine, Jeju, Korea Purpose: Bladder stones is not a rare disease, however, the number of patients with bladder stones has decreased due to improvement of nutrition, hygiene, and optimal antibiotics. Bladder stones are typically found in adults with urinary stasis, such as foreign body, benign prostate hyperplasia, spinal cord injury, and urinary tract infection, and in children with congenital genitourinary abnormality. The aim of this study was to identify the clinical and microbiological characteristics of patients with bladder stones. Materials and Methods: Patients who had bladder stones between March 9 and December were retrospectively reviewed (Jeju National University Hospital, Jeju, Korea). We analyzed the presence of spinal cord injury, cancer, previous urinary tract calculi, and urinary tract infection associated with bladder stones and also investigated the largest diameter of bladder stone, and the number of bladder stones, as well as urine and blood culture. Results: A total of 9 patients underwent cystolithotomy or cystolithotripsy. The most common presenting symptoms were voiding disturbance (n=5, 8.5%) and hematuria (n=, 5.6%). Of these patients, 7 (4.%) had positive growth of organisms. Of these organisms, Escherichia coli was found in five patients, Enterococcus fecalis in three patients, Pseudomonas aeruginosa in three patients, Klebsiella pneumoniae in two patients, Staphylococcus aureus in two patients, Proteus mirabilis in one patient, and Citrobacter in one patient. Conclusions: We believe that urinary tract infection is a major risk factor in patients with bladder stones. Proper antibiotics would be required in order to reduce the risk of formation of bladder calculi. Further investigation will be needed. Keywords: Bladder stone; Urinary tract infections; Uropathogenic coli Copyright, Korean Association of Urogenital Tract Infection and Inflammation. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution NonCommercial License (http://creativecommons.org/licenses/bync/.) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Received: March, Revised: 7 April, Accepted: May, Correspondence to: JungSik Huh Department of Urology, Jeju National University School of Medicine,, Jejudaehakro, Jeju 69756, Korea Tel: 8647776, Fax: 86477 Email: urohjs@jejunu.ac.kr This research was supported by the scientific promotion program funded by Jeju National University. No potential conflict of interest relevant to this article was reported. 9

Sum Kim, et al. 방광결석환자에서요로감염균주의특징 서론 방광결석은하부요로계의결석에서가장흔한질환이며모든결석의약 5% 정도를차지하고있다. 이질환은영양상태및위생상태와밀접한관계가있으며이러한요소가개선되었거나적절한항생제의사용으로인해선진화된나라에서는비뇨기과입원환자의약.5% 를차지할정도로흔하지않은질환이되었고, 우리나라에서도신결석과요관결석의환자는증가하는추세지만방광결석환자는선진국과마찬가지로점차감소하는추세이다., 성인과는달리소아에서는선천적인요로기형과관련된경우가많으며소아요로결석환자의약 4% 정도를차지한다. 성인의경우척수손상환자의약 7% 정도에서신결석이발생되고방광결석은약 6% 에서발생되고있다. 4 요관결석이나신결석이방광으로흘러내려와커지는경우가많지만평균수명의증가로인해전립선비대증환자의증가와, 척수손상등과같은사고의증가로인한신경탓방광등에의한요정체와도뇨관의장기유치등이방광결석을일으키기도한다. 5,6 특히불완전배설, 반복적인기구삽입혹은도뇨관삽입과점막, 털혹은무결정성침전물등으로인해요정체는방광결석뿐만아니라요로감염과관련된경우가많다. 79 척수손상환자에서요로감염을동반한방광결석은요배출을원활하기위해실시하는장기간도뇨관삽입과관련성이많다. 요소분해효소를생성하여소변을알칼리화시켜인산칼슘의결정체를형성하여결석을형성하는 Proteus mirabilis가방광결석을일으키는흔한균으로알려져있다. 6,, 본연구는방광결석환자의임상적인특징과요로감염과관련된요소를알아보고방광결석과관련된요로감염을발생시키는균주의종류와항생제의감수성을알아보고자하였다. 대상및방법 9 년 월부터 년 월까지방광결석으로인해제주대학교병원임상시험심사위원회의승인을받은이후 9명의의무기록을후향적으로분석하였다. 환자들의진단당시의연령, 성별, 임상증상, 만성질환의여부, 척수손상의존재여부, 방광결석이나요로결석의병력, 도뇨관의삽입여부, 방광결석을진단하기위해실시한영상검사에서방광결석의개수를확인하였다. 방광결석의크기는방광결석의개수가많은경우결석중가장큰것의길이를측정하였다. 모든환자에대하여일반요검경과요배양검사를실시하였다. 요검사와요배양검사의경우도뇨관이없는경우에는중간뇨를채취하여검사를하였으며도뇨관이있는경우도뇨관을막은이후일정시간이지난다음요를채취하였다. 요배양의경우이전연구와같은방식으로이용하였으며다음과같다. 5% 면양혈액한천평판 과 MacConkey 한천평판에채취한요를. ml씩접종시키고 56 o C의배양기에서 48시간배양한후형성된군락을생화학적분석법으로동정하여배양균주가 5 cfu/ml 이상의집락이배양된경우를배양균에의한요로감염으로판정하였다. 항생제감수성검사법은디스크확산법을이용하였다. 이방법은 KirbyBauer법을변경한것으로현재 NCCLS법이널리사용되고있다. 그결과를내성, 중간내성및감수성으로구분판독하였다. 요로감염으로판정이된환자군과아닌환자군으로나누어이와관련된요소를분석하였다. 요로감염으로확진이된경우균주의종류와균주의항생제에대한내성여부를알아보았다. SPSS. 프로그램 (SPSS Inc., Chicago, IL, USA) 으로카이제곱검정을이용하여통계분석을하였으며 p값이.5 이하의경우에통계적으로의미가있다고하였다. 결 과 총 9명의환자의평균연령은 67.4세 (89 세 ) 였으며, 남성이 예 (76.9%), 여성이 9예 (.%) 로남성에서많았다. 주증상으로는배뇨장애가 5명 (8.5%) 으로가장많았으며혈뇨가 명 (5.6%), 배뇨통 명 (7.7%), 복통 명 (7.7%) 이고요실금혹은우연하게발견된경우가 8명등이었다. 방광결석의개수는다양하였으며결석이 5개이상인경우 5개로할경우평균.개였으며방광결석의평균크기는. cm으로.6 cm에서 cm이었다. 방광결석의평균입원기간은 7.9일이었으며이전증례를보고한환자 예에서방광의대부분을차지하는방광결석으로인해치료와배뇨증상에대한치료를위해 5일간입원치료를하였다. 방광결석의제거수술은개복수술이 예 (8.%), lithoclast 를이용하여방광경하에파쇄를하여제거하는수술이 8예 (7.8%) 였고입원기간이각각.5± Table. Clinical characteristics Characteristic n (%) Mean±SD Gender Male Female Age (year) Symptom Hematuria Voiding disturbance Dysuria Abdominal pain Etc. Stone (n) Size of bladder stone (cm) Duration of admission (day) Cystolithotomy Litholapaxy by lithoclast Urinary tract infection SD: standard deviation. (76.9) 9 (.) 5 (8.5) 8 (.5) 8 (7.8) 67.4±..±.7.±.8 7.9±8.6.5±4.4 5.8±.

Sum Kim, et al. 방광결석환자에서요로감염균주의특징 4.4일, 5.8±.일로내시경을이용한수술이입원기간이짧았다 (p=.). 요배양검사에서균이동정된요로감염은 7예 (4.6%) 였다 (Table ). 방광결석과관련된위험요소를알기위해성별, 고혈압, 당뇨, 뇌졸중, 암의유무, 방광결석을포함한요로결석병력, 도뇨관삽입여부와방광결석치료이후합병증과의관계를분석하였으나암이방광결석과동반된 Table. Factors related with urinary tract infection (UTI) Parameter UTI (n, %) NoUTI (n, %) pvalue Gender Male Female DM CVA Cancer Spinal injury HTN Stone Hx Foley catheter insertion Complications after OP (hematuria) (.) 4 (.) (5.) 5 (8.) 6 (5.4) 6 (5.4) 7 (7.9) 7 (7.9) (5.) 5 (8.5) 5 (.8) (.6) (5.8) 9 (48.7) (56.4) (56.4) 4 (.) 8 (46.) 4 (5.9) 8 (.5) 9 (48.7) (.6) 6 (9.).6.4.69.4.99.59.5.4 DM: diabetes mellitus, CVA: cerebrovascular accident, HTN: hypertension, OP: operation for bladder stone, : presence, : absence. 경우요로감염의위험성이높게나타났으며척수손상의경우에는이번연구에포함된환자가없어서통계적의미는알수없었고수술후합병증으로방광세척을요하는혈뇨가있었다 (Table ). 요배양검사에서동정된균주는 Escherichia coli가 5예로가장많았으며 Enterococcus fecalis가 예, Pseudomonas aeruginosa가 예, Klebsiella pneumoniae가 예, Staphylococcus aureus가 예, Proteus mirabilis와 Citrobacter가각각 명이었다. 이들균중항생제감수성에대한검사에서 E. coli는 imipenam에대하여서는모두감수성이있었으나 ampicillin, amoxicillin/clavulanic acid, levofloxacin에대하여서는모두내성이있었다. E. fecalis는 imipenem에대하여모두감수성이있었으며 trimethoprim/sulfamethoxazole (TMX/SMX) 과 ciprofloxacin에대해서모두내성이발견되었다. P. aeruginosa의경우 ciprofloxacin 에대하여모두감수성이있었으며, ampicillin, cephalothin, TMP/SMX, cefotaxime에대하여모두내성이관찰되었다. K. pneumoniae의경우 amikacin, cefepime, gentamicin, tobramycin, ciprofloxacin, piperacillin/tazobactam에대하여모두감수성이있었으며 cefotaxime에는 예모두내성이발견되었다. S. caeruginosa는 lefloxacin 에대하여모두감수성이있었다 (Table ). 고찰 원발성방광결석은영양상태와위생상태에따라발생빈도에차이가있으며호발하는지역으로북아프리카, 서남아시와극동지역에서많이발생되고있는데, 4 신결석이나요관결석이이동하여방광결석이발생되는이차적방광결석이증가되고있다. 5,5 방광결석의원인은정확하게알려져있지않지만배뇨장애를유발하는척수손상, 뇌졸중등과같이기저질환이 Table. Antibiotics sensitivity of uropathogens (n=7) Antibiotics Escherichia coli (n=5) Enterococcus fecalis (n=) Pseudomonas aeruginosa (n=) Klebsiella pneumoniae (n=) Staphylococcus aureus (n=) Proteus mirabilis (n=) Citrobacter (n=) Ampicillin Amoxillin/clavulanic acid Amikacin Fosfomycin Cephalothin Cefepime Gentemicin Imipenem TMP/SMX Cefotaxime Tobramycin Levofloxacin Ciprofloxacin Piperacillin/tazobactam 5 4 4 TMP/SMX: trimethopriom/sulfamethoxazole.

Sum Kim, et al. 방광결석환자에서요로감염균주의특징 나전립선비대증등이있으며, 특히, 척수손상환자의경우약 7% 가신결석이발생되고방광결석은약 76% 에서발생되고있다. 4,69 방광결석은남성이여성보다많이발생하며요로결석의약 5% 를차지하고있으며특히여성의경우에는요정체와방광내의이물질즉봉합사혹은요실금혹은골반장기탈출증의수술치료에사용되는합성테이프나메쉬등과관련된경우가많다. 6, 본연구에서도총 9예의방광결석환자중 예가남성이었으며여성은 9예로.% 를차지하여약 5% 정도로알려진연구 에비해여성의방광결석이높았다. 증상으로는빈뇨, 절박뇨, 야간뇨와같은방광자극증상이주로나타나며, 혈뇨와재발성요로감염이발생할수있고, 방광결석이큰경우에는급성요폐와함께급성신부전을동반되는경우도있다. 4 본연구에서도빈뇨, 야간뇨, 긴박뇨등의배뇨증상이주로나타났으며혈뇨도 5.6% 에서나타났다. 방광결석의크기는대부분 5 cm 이하인경우가많으며드물게 9 cm 이상이발생되는경우도있다.,,4 본연구의경우방광결석의평균크기는. cm이었고 5개이상인경우에도 5개로환산한경우방광결석개수는평균. 개였다. 방광결석에대한치료법으로는지난 5년이상과학의발달로인해내시경기술이향상되면서보다덜침습적인수술방법이개발되어왔으며 5 본연구에서도방광결석의치료로는입원기간에서통계학적으로차이를보여내시경적인수술방법이방광결석에좋은치료법이었다. 방광결석환자의 5% 는요로감염과연관이있으며요소분해효소를만드는균인 Proteus, Pseudomonas, Ureaplasma urealyticum, Providencia, Klebsiella 등과관련되어있다.,5 원발성방광결석의원인은잘알려져있지않으며요로감염과관련된요소에대한연구가많지않다. 57 본연구에서는방광결석환자에서의요로감염과관련된요소에대한분석에서는성별, 도뇨관삽입여부, 고혈압, 당뇨, 뇌졸중등과는관련이없었으나암의경우에는통계적으로의미가있었다. 암종은방광암이 예, 전립선암, 유방암, 골수암이각각 예였다. 균이동정된요로감염은방광결석환자 9명중 7명 (4.6%) 에서동반되어다른연구에비해높게발생되었다. 도뇨관삽입과관련된방광결석은주로 P. mirabilis와관련된경우가많으며이는요를알카리성으로변화시켜도뇨관에인산칼슘을침착시키기때문이다. 6,7 특히척수손상환자에서요정체를없애기위해실시하는도뇨관을삽입한환자에서방광결석과많은관련이있으며이균이요검사에서동정된경우에는방광결석에대한초음파검사를권하고있다. 6 본연구에서도뇨관삽입과관련된요로감염균주중 P. mirabilis 는 예가동정이되었으며도뇨관삽입기간은 년이상이된경우였다. Kim 등 8 은섬지역에서,64 명의요로감염균에대한연구에서 E. coli가 44.9%, Klebsiella 균주가 8.%, Pseudomonas 균주가 7.% 로 E. coli 에의한요로감염이가장 많았다고보고하였다. 본연구에서요로감염균주를비교하기는어렵지만 E. coli가 5예 (9.4%), E. fecalis가 예 (7.6%), P. aeruginosa가 예 (7.6%), K. pneumoniae가 예 (.8%), S. aureus가 예 (.8%), P. mirabilis가 예 (5.9%), Citrobacter가 예 (5.9%) 로방광결석과관련되어발생되는요로감염의주된균은 E. coli였지만요소분해효소를발생하는균에의한요로감염은총 6예로약간높게나타났다. 지역적으로차이는있지만제주지역을대상으로한연구에서요로감염균이대표적인균인 E.coli에 ampicillin, TMX/SMX, ciprofloxacin 등의항생제에대한감수성은각각 %, 67.5%, 75.% 라고보고하였다. 8 본연구에서는 5예로요로감염이적었지만 E. coli의 ampicillin, TMX/SMX, ciprofloxacin 등에대한민감성은 %, 8%, 6% 으로 ampicillin 에대해서내성이높아방광결석으로인한요로감염의치료제로서적합하지않으며현재요로감염에많이사용되는 ciprofloxacin 보다 TMX/SMX에대한민감성이높아이약제를첫번째항생제로고려할수있을것이다. 그러나이연구의한계는방광결석이있는환자의수와요로감염의균주가너무적어서알맞은항생제를추천하기에는어려운점이많고척수손상과같은질환이전혀포함되어있지않은것이제한점으로생각된다. 결론 방광결석은남성에서주로발생되며요로감염및암과관련이있었다. 방광결석과관련된요로감염의원인균은 E. coli가가장흔하지만요소분해효소를발생하는균도 5% 를차지하였다. Imipenam 은 P. aeruginosa 예를제외하고모두감수성이있었으며 ampicilin과 amoxillin/clavulanic acid는 E. coli 에대해모두저항성이있어방광결석과동반된요로감염에서는처방하지말아야할것으로생각된다. 본연구에서환자의숫자가적고척수손상환자가전혀포함이되지않아척수손상과관련된방광결석과관련된요로감염의위험성이나균주의비교가될수없었으며, 배뇨장애를일으키는신경병성방광에대한환자가거의없어요로감염을발생시키는위험요소를비교분석이어려웠으며제한점으로생각된다. 앞으로다기관의연구를통하여방광결석환자의요로감염균의특징과내성에대한연구가더필요할것으로생각된다. REFERENCES. Benway BM, Bhayani S. Lower urinary tract calculi. In: Wein AJ, Kavoussi LR, Campbell MF, Walsh PC, eds. CampbellWalsh urology. th ed. Philadelphia: Elsevier Saunders, : 5.. Kim YG, Moon YT. Lower urinary tract calculi. In: Han SW, Kim GK, Kim DY, Kim SJ, Kim JC, Kim HJ, eds. Urology. 4th ed.

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