원저 Lab Med Online Vol. 6, No. 2: 79-87, April 임상미생물학 비뇨생식기감염유증상군과무증상군에서 Mycoplasma homins, Ureaplasma u

원저 Lab Med Online Vol. 6, No. 2: 79-87, April 2016 임상미생물학 비뇨생식기감염유증상군과무증상군에서 Mycoplasma homins, Ureaplasma urealyticum, Ureaplasma parvum 의양성률및항균제감수성양상분석 Prevalence and Antimicrobial Susceptibility of Mycoplasma hominis, Ureaplasma urealyticum and Ureaplasma parvum in Individuals With or Without Symptoms of Genitourinary Infections 권오주 1 임용관 1 오세민 1 김태형 2 최현섭 3 이승주 3 조용현 4 이미경 1 Oh Joo Kweon, M.D. 1, Yong Kwan Lim, M.D. 1, Se Min Oh, M.D. 1, Tae-Hyoung Kim, M.D. 2, Hyun-Sop Choe, M.D. 3, Seung-Ju Lee, M.D. 3, Yong-Hyun Cho, M.D. 4, Mi-Kyung Lee, M.D. 1 중앙대학교의과대학진단검사의학교실 1 비뇨기과학교실 2, 가톨릭대학교성빈센트병원비뇨기과학교실 3, 가톨릭대학교서울성모병원비뇨기과학교실 4 Departments of Laboratory Medicine 1 and Urology 2, Chung-Ang University College of Medicine, Seoul; Department of Urology 3, St. Vincent s Hospital, the Catholic University of Korea, Suwon; Department of Urology 4, St. Mary s Hospital, the Catholic University of Korea, Seoul, Korea Background: The aim of this study was to determine the prevalence and antimicrobial susceptibility of Mycoplasma hominis, Ureaplasma urealyticum, and Ureaplasma parvum among patients displaying symptoms of genitourinary infections and asymptomatic volunteers. Methods: Genitourinary samples were collected from 897 participants (365 symptomatic patients and 532 asymptomatic volunteers). The samples were analyzed using multiplex real-time PCR (Anyplex TM II, Seegene, Korea), multiplex PCR (Seeplex, Seegene), and Mycoplasma IST 2 Kit (biomerieux, France). Results: The prevalence of M. hominis, U. urealyticum, and U. parvum in the genitourinary samples of symptomatic patients compared with asymptomatic volunteers was 9.9% vs. 5.5%, 12.3% vs. 9.0%, and 36.4% vs. 30.8%, respectively. After eliminating cases of co-infections with other pathogens, there was a significant difference in the prevalence of M. hominis between symptomatic patients and asymptomatic volunteers (9.1% vs. 5.2%, P <0.05), but not in the prevalence of U. urealyticum and U. parvum organisms. When tested for antimicrobial susceptibility, more than 95.5% of each species were susceptible to tetracycline, doxycycline, josamycin, and pristamycin. More than 78.9% of Ureaplasma spp. were susceptible to azithromycin, erythromycin, and clarithromycin; however less than 4.2% of M. hominis were susceptible to these antibiotics. When tested with ofloxacin and ciprofloxacin, 40.9-58.9% and 9.1-25.0% of the three species were susceptible to these drugs, respectively. Conclusions: M. hominis is the leading causative pathogen for genitourinary infection; however the involvement of Ureaplasma spp. is debatable. For optimal antimicrobial therapy, the accurate detection of these organisms and determination of antimicrobial susceptibility is crucial considering their diverse antimicrobial susceptibility patterns. Key Words: Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum, Genitourinary, Prevalence, Antimicrobial susceptibility Corresponding author: Mi-Kyung Lee Department of Laboratory Medicine, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea Tel: +82-2-6299-2719, Fax: +82-2-6298-8630, E-mail: cpworld@cau.ac.kr Received: May 14, 2015 Revision received: June 2, 2015 Accepted: June 2, 2015 This article is available from http://www.labmedonline.org 2016, Laboratory Medicine Online This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론 Mycoplasma 과에속하는 Mycoplasma 와 Ureaplasma는직경이 0.1-1 μm로매우작고단순한구조로이루어져있는구간균모양의원핵세포이며세포벽이없는것이특징이다 [1, 2]. 인체에서분리되는 Mycoplasma 나 Ureaplasma는 15종이상존재하는것으로알려져있으며 [3], 이중비뇨생식기부위에상재하는균으로는 Mycoplasma hominis (MH), Ureaplasma urealyticum (UU), 그리고 Ureaplasma parvum (UP) 이있다 [1, 2]. eissn 2093-6338 www.labmedonline.org 79

Ureaplasma는특징적으로요소 (urea) 를분해할수있는효소를가지고있으며균의성장에요소를필요로하는균속으로 1954 년 Shepard 등 [4] 에의해발견된후 1974년 Ureaplasma로명명되었다 [5]. 당시에는 Ureaplasma 중 UU만이인체에서분리되는균으로여겨졌으나, 2002년 16S rrna 염기서열분석을통해 UU가두개의 biovar로나누어졌으며이중 biovar 1이 UP로분리, 명명되었다 [6]. 현재 UP는혈청형 1, 3, 6, 그리고 14를포함하며, UU는나머지 10개의혈청형을포함한다 [3]. MH, UU, 그리고 UP는비임균성요도염, 전립선염, 자궁경부염, 자궁내막염, 산후열, 불임, 조기분만진통, 조기양막파열등과관련이있다는보고가있으나 [1, 2, 7-9], 건강한성인남녀의비뇨생식기에도정상상재균으로존재하기때문에그병원성에대하여는논란이있어왔다 [1, 2, 7, 10]. 따라서이들균들은단순히균이검출되었다는결과만으로치료를시작하지않고임상증상을고려하여치료여부를선택하게된다 [11]. MH와 Ureaplasma spp. 는세포벽이없기때문에세포벽을표적으로하는 β-lactams, sulfonamides, trimethoprim, 그리고 rifampin 등의약제에자연내성을보인다 [1, 2]. 이들균종들은일반적인방법으로는배양및항균제감수성검사의수행이어려워감염증의치료에 tetracycline 이과거부터경험적으로사용되었으나 [2], 내성을갖는균주의비율이 10-40% 수준으로증가하여 [12], 최근에는주로 macrolide나 fluoroquinolone 계열약제들이치료에사용되고있다 [3]. 하지만이들약제에대한내성역시보고되고있으며 [13], 이와더불어특히 macrolide의경우 MH와 Ureaplasma spp. 가서로다른항균제감수성양상을보인다 [1]. 따라서적절한향균제의선택을위하여정확한균종동정과항균제감수성검사가중요하다. 국내에서임산부혹은비뇨생식기계감염의증상이있는환자에서 MH, UU의양성률에대한연구는종종있어왔으나 [14-17], UP 및무증상건강인까지포함한광범위한양성률분석연구는드물다. 국내에서분리되는균주들의항균제감수성양상에대한보고역시제한적이며 [18, 19], 특히 UP의경우는거의전무한실정이다. 따라서저자들은이전연구 [20] 를수행하면서얻은부가적인자료를바탕으로, 성별, 검체별, 그리고증상유무에따른 MH, UU, UP 의양성률분석을시행하여해당균들의임상적중요성에대해고찰해보고자하였으며, 이와더불어항균제감수성검사결과를분석하여국내에서분리되는이들균종에대한항균제감수성양상을파악하고자하였다. 대상및방법 1. 대상과검체 연구대상은유증상군과무증상군으로나누어총 897 명이모집 되었다. 성매개감염이의심되어비뇨기과및산부인과외래를방문한 365명이유증상군으로분류되었으며이중남성은 164명으로소변검체를채취하였고, 여성은 201명으로자궁경관내면봉법 (endocervical swab) 으로자궁경관내세포검체를얻었다. 건강검진을위해병원을찾은 532명 ( 남성 346명, 여성 186명 ) 이무증상군으로분류되었고모두소변검체를채취하였다. 채취한검체들은즉시냉장하여이송배지등의첨가없이중앙검사실인중앙대학교병원진단검사의학과로이송하였으며검체채취후 48시간이내에모든검사를수행하였다. 본연구는중앙대학교병원 ( 승인번호 C2015087(1545)) 및가톨릭대학교의과대학 ( 승인번호 XC12O- IMI0003V) 생명윤리심의위원회의승인을받았다. 2. 검사방법 MH, UU의검출에는두가지핵산증폭검사와 Mycoplasma IST 2 Kit (biomerieux, Marcy-l Etoile, France) 를사용하였다. 핵산증폭검사로는 multiplex real-time PCR 검사인 Anyplex II STI-7 Detection Kit (Seegene, Seoul, Korea) 와 multiplex PCR 검사인 Seeplex STD6 ACE Detection Kit (Seegene, Seoul, Korea) 를사용하였다. UP는이중검사가가능한 Anyplex II STI-7 Detection Kit와 Mycoplasma IST 2 Kit만을이용하였다. 1) DNA 추출자궁경관내세포검체와소변검체는원심분리후 1 phosphate-buffered saline 1 ml에재부유시킨후 QIAamp DNA Mini Kit (Qiagen, Hilden, Germany) 로제조사의지시에따라 DNA를추출하였다. 2) Multiplex real-time PCR (Anyplex II STI-7 Detection Kit) PCR은 CFX96 real-time thermocycler (Bio-Rad, Hercules, CA, USA) 를사용하여 50 에서 4분, 95 에서 15분간반응시킨후, 95 에서 30초, 60 에서 1분, 72 에서 30초의반응조건으로 50 회반복하였으며융해온도 (melting temperature) 는 55 에서 85 (5초/0.5 ) 로가온하며분석하였다. 본검사로검출가능한균종은 MH, UU, UP, C. trachomatis (CT), N. gonorrhoeae (NG), T. vaginalis (TV), 그리고 M. genitalium (MG) 였다. 3) Multiplex PCR (Seeplex STD6 ACE Detection Kit) PCR은 GeneAmp PCR System 9700 (Applied Biosystems, Carlsbad, CA, USA) 을사용하여제조사의지침대로시행하였으며, 증폭산물을아가로스겔전기영동후 ethidium bromide로염색하여밴드의크기로분석하였다. 본검사로검출가능한균종은 MH, UU, CT, NG, TV, 그리고 MG였다. 80 www.labmedonline.org

4) Mycoplasma IST 2 Kit와항균제감수성검사 Mycoplasma IST 2 Kit는 MH와 Ureaplasma spp. 의배양, 동정, 균수계산, 항균제감수성검사를한번에시행할수있으며모두 22개의구획 (well) 으로구성된스트립과 R1, R 2 시약으로구성되어있지만, UU와 UP의감별은불가능하다. 약 500 μl의소변혹은 100 μl의자궁경관내세포검체를 R1 solution에접종하고, 이를 R 2 vial과섞어준후보텍싱하였다. 이용액을 55 μl씩 22개의구획에분주하고각구획에광유 (mineral oil) 를떨어뜨린후스트립을 37 에서 48시간배양하였다. 각구획의배지색깔이노란색에서붉은색으로바뀐경우를양성으로판독하였으며, colony forming unit이 10 4 /ml인경우만해당균에대한양성으로판정하였다. 항균제감수성검사의경우 kit의스트립에 doxycycline (DOT), josamycin (JOS), ofloxacin (OFL), erythromycin (ERY), tetracycline (TET), ciprofloxacin (CIP), azithromycin (AZI), clarithromycin (CLA), 그리고 pristinamycin (PRI) 등 9개약제에대하여농도별로두개씩총 18개의 well이존재하며, 해당 well에서의양성반응을확인하여감수성 (S), 중간내성 (I), 혹은내성 (R) 여부를제조사의지시및 Clinical and Laboratory Standards Institute (CLSI) 가이드라인에따라판정하였다 [21]. 3. 평가방법 1) 양성률평가증상여부, 검체종류, 성별등에따른각균종의양성률을비교분석하였다. MH의경우 Anyplex II STI-7 Detection Kit, Seeplex STD6 ACE Detection Kit, Mycoplasma IST2 kit 중단하나의검사에서라도양성이면해당검체를양성이라판단하였다. UU의경우도마찬가지로 Anyplex II STI-7 Detection Kit, Seeplex STD6 ACE Detection Kit, Mycoplasma IST2 kit 중하나이상의검사에서양성인경우해당검체를양성이라판단하였으나, Mycoplasma IST2 kit만단독으로양성인경우는 UU와 UP의감별이불가능하므로제외하였다. UP의경우 Anyplex II STI-7 Detection Kit에서양성인검체는모두양성으로판단하였다. 유증상군과무증상군의양성률비교평가에서는두종류의 multiplex PCR을통해얻은 CT, NG, TV, MG의검사결과를이용하여해당균들에의한가림효과 (mask effect) 의가능성을배제하였다. 2) 항균제감수성검사항균제감수성검사는 Mycoplasma IST2 kit로시행하였으며, 증상여부, 검체종류, 성별등에따른각균종의결과를비교분석하였다. Mycoplasma IST2 kit와핵산증폭검사에서중복감염을의심할수있는결과를보인검체들과 UU, UP의결과를모두통합하여 Ureaplasma spp. 에대한항균제감수성검사결과를별도로분석하였다. 분석시중간내성은감수성률및내성률의계산에서제외하였다. 4. 통계학적분석양성률및항균제감수성검사의비교는피셔정확검정 (Fisher s exact test) 을이용하였으며통계분석은 Microsoft Excel 2010 (Microsoft, New York City, NY, USA) 과 SPSS (IBM, Chicago, IL, USA) 를이용하였으며 P값 0.05 미만을통계학적인유의성을가지는기준으로하였다. 결과 1. 검체의종류, 성별및증상유무에따른 MH, UU, UP의양성률 897개검체의종류별, 성별및증상유무에따른각균의양성률은 Table 1과같다. 전체검체에서유증상군의 MH, UU, UP의양성 Table 1. The prevalence of Mycoplasma hominis and Ureaplasma species according to the type of specimens, sex, and symptom (including overlapping results) Species Symptoms Entire specimens Total Male Female Specimens without other pathogens* Urine Endocervical swab Urine + - + - + - + - P value P value P value (N=365) (N=532) (N=341) (N=522) (N=164) (N=346) (N=186) (N=201) MH No. 36 29 31 27 5 8 22 30 % 9.9 5.5 <0.01 9.1 5.2 <0.01 3.1 2.3 0.56 11.8 14.9 UU No. 45 48 33 48 21 31 19 22 % 12.3 9.0 <0.01 9.7 9.2 0.81 13.0 8.9 0.16 10.2 11.0 UP No. 133 164 117 150 24 63 103 107 % 36.4 30.8 <0.01 34.3 28.7 0.10 14.9 18.1 0.45 55.4 53.2 *Including Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium. Abbreviations: MH, Mycoplasma hominis; UU, Ureaplasma urealyticum; UP, Ureaplasma parvum. www.labmedonline.org 81

률은각각 9.9%, 12.3%, 36.4% 로무증상군 5.5%, 9.0%, 30.8% 에비해모두유의하게높았다 (P <0.05). 하지만임상증상을유발할수있는다른균 (CT, NG, TV, MG) 과의중복감염검체 (N =34) 를제외하였을경우에는 MH만이유증상군에서무증상군보다의미있게높은양성률 (9.1% vs. 5.2%, P <0.01) 을보였으며, UU와 UP의경우에는두군간양성률에유의한차이가없었다 (P >0.05). 남성의경우소변검체에서각균의양성률은유증상군과무증상군간에유의한차이가없었으며, 임상증상을유발할수있는다른균과의중복감염검체를제외한경우도역시차이는없었다 ( 결과제시하지않음 ). 여성의경우무증상여성소변검체에서 UP 가 55.4% 로가장많았으며 MH 11.8%, UU 10.2% 순이었다. 유증상여성의자궁경관내세포검체도마찬가지로 UP가 53.2% 로가장많았으며 MH는 14.9%, UU는 11.0% 였다. 단, 유증상군과무증상군의검체가상이하여두군간의직접비교는시행하지않았다. MH, UU, UP, Ureaplasma spp. 양성검체중 Mycoplasma IST2 kit 에서검출되어항균제감수성검사결과를확보한검체의수는각각 24, 22, 95, 131개였다. MH의경우 DOT, JOS, TET, PRI에 95% 이상의감수성을보였으나 OFL, CIP, AZI에는각각 54.2%, 25.0%, 4.2% 의감수성을보였고 ERY와 CLA에는모두비감수성이었다. UU의경우 DOT, JOS, ERY, TET, AZI, CLA, PRI에 80% 이상의감수성을보였으나, OFL에감수성인균주는 40.9% 에불과했으며 CIP에는 9.1% 에서만감수성이었다. UP의경우 UU와유사하게 DOT, JOS, TET, AZI, CLA, PRI에 80% 이상이감수성이었으나, OFL에감수성인균주는 40.9% 로낮았으며, CIP에는 17.9% 에서감수성이었다. UU 와 UP 및중복감염검체 (N =25) 를포함하여 Ureaplasma spp. 로통합 (N =131) 하여분석하였을경우도마찬가지로 DOT, JOS, TET, AZI, CLA, PRI에는 80% 이상의감수성을보였으나, CIP에는 14.5% 에서감수성이었다. 2. 항균제감수성양상 1) 균종별항균제감수성양상 분석한모든균에대한항균제감수성양상은 Table 2 와같다. 2) 증상유무에따른항균제감수성양상의차이 증상유무에따른항균제감수성검사결과의차이는 Table 3 과 같다. MH 의경우두군간의감수성결과에유의한차이를보이는 Table 2. Antimicrobial susceptibility patterns of Mycoplasma hominis, Ureaplasma urealyticum, and Ureaplasma parvum Species DOT JOS OFL ERY TET CIP AZI CLA PRI MH (N=24) S No. 24 23 13 0 24 6 1 0 23 % 100.0 95.8 54.2 0 100.0 25.0 4.2 0 95.8 I No. 0 0 4 1 0 8 5 2 - % 0 0 16.7 4.2 0 33.3 20.8 8.3 - R No. 0 1 7 23 0 10 18 22 1 % 0 4.2 29.2 95.8 0 41.7 75.0 91.7 4.2 UU (N=22) S No. 21 22 9 19 21 2 18 20 22 % 95.5 100.0 40.9 86.4 95.5 9.1 81.8 90.9 100.0 I No. 0 0 11 2 0 5 2 1 - % 0 0 50.0 9.1 0 22.7 9.1 4.5 - R No. 1 0 2 1 1 15 2 1 0 % 4.5 0 9.1 4.5 4.5 68.2 9.1 4.5 0 UP (N=95) S No. 93 95 56 75 91 17 81 79 95 % 97.9 100.0 58.9 78.9 95.8 17.9 85.3 83.2 100.0 I No. 1 0 27 8 2 48 4 5 - % 1.1 0 28.4 8.4 2.1 50.5 4.2 5.3 - R No. 1 0 12 12 2 30 10 11 0 % 1.1 0 12.6 12.6 2.1 31.6 10.5 11.6 0 Ureaplasma spp. (N=131) S No. 128 131 70 102 126 19 108 108 131 % 97.7 100.0 53.4 77.9 96.2 14.5 82.4 82.4 100.0 I No. 1 0 46 12 2 54 8 7 - % 0.8 0 35.1 9.2 1.5 41.2 6.1 5.3 - R No. 2 0 15 17 3 58 15 16 0 % 1.5 0 11.5 13.0 2.3 44.3 11.5 12.2 0 The breakpoints (mg/l) are as follows: DOT S 4, R 8; JOS S 2 R 8; OFL S 1, R 4; ERY S 1, R 4; TET S 4, R 8; CIP S 1, R 2; AZI S 0.12, R 4; CLA S 1, R 4; PRI R 2. Abbreviations: MH, Mycoplasma hominis; UU, Ureaplasma urealyticum; UP, Ureaplasma parvum; DOT, Doxycycline; JOS, Josamycin; OFL, Ofloxacin; ERY, Erythromycin; TET, Tetracycline; CIP, Ciprofloxacin; AZI, Azithromycin; CLA, Clarithromycin; PRI, Pristamycin; S, Susceptible; I, Intermediate; R, Resistant. 82 www.labmedonline.org

약제는없었다. UU의경우유증상군이무증상군에비해 OFL에대한감수성률이유의하게낮았으며 (16.7% vs. 70.0%, P <0.05), CIP에대한내성률이유의하게높았다 (91.7% vs. 40.0%, P <0.05). UP의경우유증상군이무증상군에비해 ERY과 AZI에대한감수성률이유의하게낮았으며 ( 각각 71.4 vs. 93.8, 77.8 vs. 100.0, P <0.05), 특히무증상군에서는 AZI에내성인균주가한균주도없었다. 남성소변검체에서남성유증상군과무증상군간항균제감수성결과를추가로비교하였지만두군간유의한차이는없었다 ( 결과제시하지않음 ). 3) 검체별항균제감수성양상소변검체와자궁경부내세포검체로나누어분석한항균제감수성양상은 Table 4와같다. MH의경우자궁경부내세포검체에비해소변검체에서 CIP와 AZI에대한감수성률이높은결과를보였고 (50.0% vs. 20.0%, 25.0% vs. 0.0%), 나머지검체에서는두검체간감수성률의차이를보이지않았다. UU의경우소변검체에서 OFL과 CIP를제외한나머지항균제에대한감수성률이높았다. UP의경우소변검체에서 DOT, JOS, TET, PRI를제외한나머지항균제에대한감수성률이높았으며, 증상유무에따른항균제감수성양상의직접비교는검체별로유증상과무증상군의비율이달 Table 3. Antimicrobial susceptibility patterns of each microorganism according to the symptoms from all types of specimens Species Symptoms DOT JOS OFL ERY TET CIP AZI CLA PRI + - + - + - + - + - + - + - + - + - MH S (%) 100.0 100.0 95.0 100.0 55.0 50.0 0.0 0.0 100.0 100.0 20.0 25.0 0.0 0.0 0.0 0.0 95.0 100.0 I (%) 0.0 0.0 0.0 0.0 15.0 25.0 5.0 0.0 0.0 0.0 35.0 25.0 20.0 25.0 5.0 25.0 0.0 - R (%) 0.0 0.0 5.0 0.0 30.0 25.0 95.0 100.0 0.0 0.0 45.0 25.0 80.0 50.0 95.0 75.0 5.0 0.0 UU S (%) 91.7 100.0 100.0 100.0 16.7* 70.0* 83.3 90.0 91.7 100.0 0.0 20.0 75.0 90.0 91.7 90.0 100.0 100.0 I (%) 0.0 0.0 0.0 0.0 66.7 30.0 16.7 0.0 0.0 0.0 8.3 40.0 16.7 0.0 8.3 0.0 0.0 - R (%) 8.3 0.0 0.0 0.0 16.7 0.0 0.0 10.0 8.3 0.0 91.7* 40.0* 8.3 10.0 0.0 10.0 0.0 0.0 UP S (%) 100.0 93.8 100.0 100.0 57.1 62.5 71.4* 93.8* 98.4 90.6 12.7 28.1 77.8* 100.0* 82.5 84.4 100.0 100.0 I (%) 0.0 3.1 0.0 0.0 28.6 28.1 11.1 3.1 0.0 6.3 52.4 46.9 6.3 0.0 17.5 15.6 0.0 - R (%) 0.0 3.1 0.0 0.0 14.3 9.4 17.5 3.1 1.6 3.1 34.9 25.0 15.9* 0.0* 0.0 0.0 0.0 0.0 Ureaplasma S (%) 98.8 95.6 100.0 100.0 48.8 62.2 69.8* 93.3* 97.7 93.3 9.3* 24.4* 74.4* 97.8* 81.4 84.4 100.0 100.0 spp. I (%) 0.0 2.2 0.0 0.0 37.2 31.1 12.8 2.2 0.0 4.4 40.7 42.2 9.3 0.0 12.7 13.3 0.0 - R (%) 1.2 2.2 0.0 0.0 14.0 6.7 17.4 4.4 2.3 2.2 50.0 33.3 16.3* 2.2* 5.8 2.2 0.0 0.0 The breakpoints (mg/l) are as follows; DOT S 4, R 8; JOS S 2 R 8; OFL S 1, R 4; ERY S 1, R 4; TET S 4, R 8; CIP S 1, R 2; AZI S 0.12, R 4; CLA S 1, R 4; PRI R 2. *P <0.05. Abbreviations: MH, Mycoplasma hominis; UU, Ureaplasma urealyticum; UP, Ureaplasma parvum; DOT, Doxycycline; JOS, Josamycin; OFL, Ofloxacin; ERY, Erythromycin; TET, Tetracycline; CIP, Ciprofloxacin; AZI, Azithromycin; CLA, Clarithromycin; PRI, Pristamycin; S, Susceptible; I, Intermediate; R, Resistant. Table 4. Antimicrobial susceptibility patterns of each microorganism according to the type of specimens Species Urine Endocervical swab DOT JOS OFL ERY TET CIP AZI CLA PRI DOT JOS OFL ERY TET CIP AZI CLA PRI MH S (%) 100.0 100.0 50.0 0.0 100.0 50.0 25.0 0.0 100.0 100.0 95.0 55.0 0.0 100.0 20.0 0.0 0.0 100.0 I (%) 0.0 0.0 25.0 0.0 0.0 25.0 25.0 25.0 0.0 0.0 0.0 15.0 5.0 0.0 35.0 20.0 5.0 - R (%) 0.0 0.0 25.0 100.0 0.0 25.0 50.0 75.0 0.0 0.0 5.0 30.0 95.0 0.0 45.0 80.0 95.0 0.0 UU S (%) 100.0 100.0 56.3 93.8 100.0 12.5 93.8 93.8 100.0 83.3 100.0 0.0 66.7 83.3 0.0 50.0 83.3 100.0 I (%) 0.0 0.0 43.8 0.0 0.0 25.0 0.0 0.0 0.0 0.0 0.0 66.7 33.3 0.0 16.7 33.3 16.7 - R (%) 0.0 0.0 0.0 6.3 0.0 62.5 6.3 6.3 0.0 16.7 0.0 33.3 0.0 16.7 83.3 16.7 0.0 0.0 UP S (%) 94.9 100.0 61.5 94.9 89.7 28.2 97.4 87.2 100.0 100.0 100.0 57.1 67.9 100.0 10.7 76.8 80.4 100.0 I (%) 2.6 0.0 30.8 2.6 5.1 51.3 2.6 12.8 0.0 0.0 0.0 26.8 12.5 0.0 50.0 5.4 0.0 - R (%) 2.6 0.0 7.7 2.6 5.1 20.5 0.0 0.0 0.0 0.0 0.0 16.1 19.6 0.0 39.3 17.9 19.6 0.0 Ureaplasma spp. S (%) 96.6 100.0 59.3 94.9 93.2 22.0 96.6 88.1 100.0 98.6 100.0 48.6 63.9 98.6 8.3 70.8 77.8 100.0 I (%) 1.7 0.0 35.6 1.7 3.4 42.4 1.7 10.2 0.0 0.0 0.0 34.7 15.3 0.0 40.3 9.7 1.4 - R (%) 1.7 0.0 5.1 3.4 3.4 35.6 1.7 1.7 0.0 1.4 0.0 16.7 20.8 1.4 51.4 19.4 20.8 0.0 The breakpoints (mg/l) are as follows: DOT S 4, R 8; JOS S 2 R 8; OFL S 1, R 4; ERY S 1, R 4; TET S 4, R 8; CIP S 1, R 2; AZI S 0.12, R 4; CLA S 1, R 4; PRI R 2. Abbreviations: MH, Mycoplasma hominis; UU, Ureaplasma urealyticum; UP, Ureaplasma parvum; DOT, Doxycycline; JOS, Josamycin; OFL, Ofloxacin; ERY, Erythromycin; TET, Tetracycline; CIP, Ciprofloxacin; AZI, Azithromycin; CLA, Clarithromycin; PRI, Pristamycin; S, Susceptible; I, Intermediate; R, Resistant. www.labmedonline.org 83

라시행하지않았다. 고찰 이번연구에서무증상건강인의 MH와 UU의양성률은각각 5.5% 와 9.0% 였는데, 이는이전에국내에서수행된무증상의건강한사람을대상으로한연구와비교하면낮은수준이다. Kim 등 [22] 은 2011년 709개의검체에대한 MH와 UU의양성률연구결과무증상의건강한사람에서양성률은각각 11.6% 와 22.1% 라보고하였다. 본연구와동일한검사 kit (Seeplex STD6 ACE Detection Kit) 를사용한연구임에도양성률의차이가나타나는이유로는검체종류의차이를우선생각할수있겠는데, Kim 등 [22] 의연구에서는여성에서오직질세포검체 (vaginal swab) 만채취하였지만본연구에서무증상여성은소변검체만을채취하였다. 그리고특히여성의경우체내에스트로겐의수준및성생활정도가 Ureaplasma spp. 의양성률과관련이있는것으로알려져있어 [23], 두연구간에연구참여자의연령구성에차이가있었을가능성도고려할수있으나, 해당연구에서연령에대한정보를밝히지않아비교할수없었다. 국외에서수행된무증상여성을대상으로한연구들에서는 MH의경우 11.3-35.0% [24, 25], UU의경우 6.1-19.0% [3, 7, 25-27] 의양성률이보고되어있으며이번연구에서무증상여성의소변검체양성률인 14.9%, 11.0% 와큰차이를보이지않았다. UP의경우국내에서수행된연구중무증상의건강한사람을대상으로한다른연구는찾을수없었으며, 국외에서수행된연구들에서는 17.9-87.0% 로연구마다다양하게보고하고있다 [3, 7, 26, 27]. 이번연구에서국내무증상인의 UP 양성률은 30.8% 였으며남성 18.1%, 여성 53.2% 로여성이남성보다높았다. 유증상군에서 MH, UU, UP의양성률은각각 9.9%, 12.3%, 36.4% 였다. 기존국내에서수행된연구에서 Moon 등 [16] 은유증상군에서양성률을각각 2.9%, 17.6%, 3.7% 로보고하였는데, MH와 UP의경우본연구와큰차이를보인다. 본연구에서유증상검체 347개중여성의검체가 186개였던반면해당연구에서는총 626 개의검체중여성검체는오직 65개만포함되어있어, 연구에포함된여성의분포가양성률에영향을주었을것으로생각되나그차이가매우크므로국내에서의추가적인연구가필요할것으로생각된다. 유증상군과무증상군간의양성률은다른원인균들 (CT, NG, TV, MG) 과의중복감염을고려하지않았을경우에는 MH, UU, UP 모두두군간에유의한차이를보였으나, 중복감염된경우를제외하면 MH만이차이가있었다. 즉 MH는중복감염을제외했을경우에도양성률이각각 9.1% 와 5.2% 로두군간에통계학적으로유의한차이를보여성매개감염의원인균일가능성을시사하며, 반대 로 UU와 UP는질환의원인균일가능성에의심을제시할수있는결과라할수있다. 다만, UU의질내감염이있는경우세균성질염을일으키는여러균주의질내집락형성이 2배이상증가한다고알려져있어 [28], 본연구에서다른원인균들과중복감염된 34 개의검체가이런경우에해당하는것으로생각할수있다. 남성의소변에서각균의양성률은두군간에차이가없었는데이는다른원인균의중복감염을배제한후에도마찬가지였으며따라서남성에서 MH, UU, UP는임상증상발현과큰관련은없는것으로판단할수있다. 남성에서 UP가불임과관련될수있다는보고가있으나 [29], 본연구에서는불임에대한접근은시행하지않았다. MH는 lincosamide 제제인 clindamycin과 lincomycin에감수성을보이나 ERY이나 AZI 등 macrolides에는내성을보이는것으로알려져있는데 [1], 본연구에서도이와마찬가지로 macrolide 제제인 ERY, AZI, CLA에대한내성률이각각 95.8%, 75.0, 91.7% 로매우높게나타났다. DOT와 TET에대한내성은관찰되지않았으며 JOS와 PRI 등에대해서도높은감수성률을보였다. 반면최근내성이증가하고있는 OFL과 CIP는각각 29.2%, 41.7% 의내성률을보여 fluoroquinolone 제제를 MH의치료에 1차약제로사용하는것은어려울것으로사료된다. 2010년터키에서는 OFL과 CIP의내성률을 60% 와 40% 로보고한바있는데 [30], 본연구에서는이보다는낮거나유사한수준의내성률을보였다. 2009년 Koh 등 [19] 은국내에서분리되는 MH의 TET, OFL과 CIP에대한내성률을각각 50.0%, 0.0%, 50.0% 로보고하였는데, 해당연구는오직 2예의균주에대한결과여서직접비교에무리가있다. 다만, TET의경우본연구에서는 100% 감수성결과를보인반면 Koh 등 [19] 의연구에서는감수성이 50%, 내성이 50% 라보고하였으며, 국외에서는신생아에서분리되는 MH의약 40% 가 TET에내성이라는보고도있어 [12] 향후 TET의내성에대한면밀한관찰이필요할것으로생각된다. UU의경우는 MH와반대로 macrolides에는감수성을보이고 lincosamide 제제에내성을보이는것으로알려져있다 [1]. 이번연구에서 ERY, AZI, CLA에는감수성률이 80% 이상으로나타났으며 DOT, JOS, TET, PRI 등도높은감수성률을보였다. 하지만 OFL에대한내성률은 9.1% 였고 CIP에 68.2% 의내성률을보여 MH보다높은수준의내성을보였다. 이는 2010년터키에서보고된 [30] 85.2%, 92.6% 보다는낮은수준이지만, 국내에서 Koh 등 [19] 이 2009년 105개의검체를분석하여보고한 4.8% 와 21.9% 보다높은수준이므로국내에서의내성률은이전보다증가한것으로판단할수있다. 또한이번연구에서유증상군이무증상군보다 CIP의내성률이유의하게높았으며 (91.7% vs. 40.0%, P <0.05), OFL의감수성또한유증상군에서유의미하게낮았는데 (16.7% vs. 70.0%, P <0.05), 이로미루어보아도국내유증상군의 UU 치료에있어 84 www.labmedonline.org

fluoroquinolone 계열약제의사용은가급적피해야할것으로생각된다. UP의경우 UU와항균제감수성양상이유사하게나타나 ERY, AZI, CLA 등의 macrolide에 80% 이상의감수성률을보였으며 DOT, JOS, TET, PRI 또한높은수준의감수성률을보였다. OFL과 CIP의내성률은각각 12.6% 와 31.6% 로 UU와유사한수준이거나낮았다. ERY와 AZI의경우에는유증상군이무증상군보다유의하게낮은감수성률을보여, 경험적항균제치료에있어이들약제의사용에신중을기해야하겠다. 국내에서 UP 단독으로항균제감수성양상을분석하여보고한예는매우드물어, 비교할대상을찾지못하였으며따라서본연구의결과는향후 UP의항균제감수성양상의연구에있어큰의미를가질것으로생각된다. 이번연구는몇가지한계가있는데, 첫번째로는균의동정에있어표준검사법이라할수있는직접염기서열분석법을통해각균을확인하지않고 multiplex PCR을통해검출했다는점이며따라서 multiplex PCR의정확도에결과가영향을받을수있다는것이다. 하지만, 본연구에서사용된 multiplex PCR kit의경우이전연구들에서각균의검출에대한민감도와특이도가 monoplex PCR 을기준법으로보았을때모두 99% 이상의수준인것으로보고되어있으며 [16, 20], 본연구의경우두가지방법의핵산증폭검사및이와더불어직접배양법원리가적용된 Mycoplasma IST 2 Kit를함께사용하여각균을검출하였으므로검사의정확도는충분히확보하였다고판단할수있겠다. 두번째로여성의경우무증상군에서는소변검체만, 유증상군에서는자궁경관내세포검체만채취하였기에, 반대의경우인무증상군자궁경관내세포검체, 그리고유증상군소변검체에서는각균의양성률을파악하지못하였다는점이다. 따라서추후해당군들에대한양성률연구가필요할것으로생각된다. 결론적으로, 이번연구에서 MH, UU, UP는유증상군에서는각각 9.9%, 12.3%, 36.4% 의양성률을보였으며무증상군에서는각각 5.5%, 9.0%, 30.8% 의양성률을보였다. 다른원인균에대한중복감염균을배제했을경우 MH를제외하고는두군간유의한양성률차이는없었다. 항균제감수성양상은세균종모두 fluoroquinolone 약제들에상당한수준의내성을보였으므로치료약제선택에주의가필요할것으로생각되며, MH와 Ureaplasma spp. 가서로다른항균제감수성양상을보이므로정확한동정과항균제감수성검사가적절한치료약제선택에필수적이라사료된다. 본연구는국내에서수행된연구중유일하게 UP에대한성별, 증상유무별, 검체별양성률및항균제감수성양상을포함하고있어그가치가있다. 요약 배경 : 저자들은비뇨생식기증상을가진환자및무증상지원자들에서 Mycoplasma hominis (MH), Ureaplasma urealyticum (UU), 그리고 Ureaplasma parvum (UP) 에대한국내유병률및항균제감수성양상을분석하였다. 방법 : 897명의참여자 ( 유증상군 365명, 무증상군 532명 ) 에서얻은검체를 multiplex real-time PCR (Anyplex TM II, Seegene, Korea), multiplex PCR (Seeplex, Seegene), 그리고 Mycoplasma IST 2 Kit (biomerieux, France) 를사용하여분석하였다. 결과 : 유증상군에서 MH, UU, UP의양성률은각각 9.9%, 12.3%, 36.4% 였고무증상군에서는각각 5.5%, 9.0%, 30.8% 였다. 증상을일으킬수있는다른원인균에중복감염된사례를제외시킨후, MH는유증상군과무증상군간의미있는차이를보였으나 (9.1% vs. 5.2%, P <0.05) UU와 UP는그렇지않았다. 항균제감수성검사결과세균주의 tetracycline, doxycycline, josamycin, pristamycin 에대한감수성률은 95.5% 이상이었으며, 78.9% 이상의 Ureaplasma spp. 가 azithromycin, erythromycin, 그리고 clarithromycin에감수성을보였으나 MH는감수성률이 4.2% 미만이었다. Ofloxacin과 ciprofloxacin의감수성률은각각 40.9-58.9%, 9.1-25.0% 였다. 결론 : 본연구결과 M. hominis는비뇨생식기감염질환의병원균으로작용한다판단할수있겠으나, Ureaplasma spp. 의병원성에대해서는의문이든다. 항균제감수성양상분석결과 MH와 Ureaplasma spp. 가서로다른항균제감수성양상을보이므로정확한동정과항균제감수성검사가적절한치료약제선택에필수적이라사료된다. 이해관계 저자들은본연구와관련하여해당회사와이해관계가없음. REFERENCES 1. Washington CW, Stephen DA, et al. eds. Koneman s color atlas and textbook of diagnostic microbiology. 6th ed. Lippincott Williams & Wilkins, 2006. 2. Waites K and Taylor-Robinson D. Mycoplasma and Ureaplasma. In: Versalovic J, ed. Manual of clinical microbiology. 10th ed. Washington DC: ASM Press, 2010:970-85. 3. Maruška M, Darja K, Jovan M, Mojca M. Clinical role of Ureaplasma parvum and Ureaplasma urealyticum presence in female lower uro- www.labmedonline.org 85

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