대한진단검사의학회지 : 제 25 권제 6 호 2005 Korean J Lab Med 2005; 25: 411-5 임상미생물학 원외획득요로감염그람음성간균에대한 Cefatrizine-Clavulanic Acid의시험관내항균력 노경호 1,2 염종화 2 용동은 1,2 최성학 3 이재걸 3 유무희 3 이경원 1,2 정윤섭 1,2 연세대학교의과대학진단검사의학교실 1, 세균내성연구소 2, 동아제약 ( 주 ) 연구소 3 In Vitro Activities of Cefatrizine-Clavulanic Acid against Gram-Negative Bacilli Isolated from Community-acquired Urinary Track Infection Kyoung Ho Roh, M.D. 1,2, Jong Hwa Yum, Ph.D. 2, Dongeun Yong, M.D. 1,2, Sung Hak Choi, M.S. 3, Jae Keol Rhee, Ph.D. 3, Moohi Yoo, Ph.D. 3, Kyungwon Lee, M.D. 1,2, and Yunsop Chong, Ph.D. 1,2 Departments of Laboratory Medicine 1 and Research Institute of Bacterial Resistance 2, Yonsei University College of Medicine, Seoul; Research Laboratory, Dong-A Pharmaceutical Co., Ltd. 3, Yongin, Korea Background : A high proportion of currently isolated gram-negative bacilli are resistant to -lactams by producing -lactamases. -lactam and -lactamase inhibitor combinations have been successfully used to overcome the resistance. In this study, in vitro antimicrobial activity of a new combination, cefatrizine-clavulanic acid, was determined against gram-negative bacilli isolated from community-acquired urinary track infections. Methods : Nonduplicate strains of Enterobacteriaceae, isolated in 2003 from urine specimens of outpatients and inpatients of less than 3 hospital days at Severance Hospital, were tested by the NCCLS agar dilution method. Results : Of a total of 204 isolates, 144 (71%) were Escherichia coli and 30 (15%) were Klebsiella spp. MIC50 and MIC90 of cefatrizine for E. coli were 2 g/ml and 16 g/ml, respectively. MIC90s of both cefaclor and cefoxitin were also 16 g/ml. MIC50 and MIC90 of cefatrizine-clavulanic acid for E. coli were 1 g/ml and 4 g/ml, respectively, which were 1/2-1/4 of those of cefaclor and cefoxitin. For Klebsiella spp., MIC90 of cefatrizine was 4 g/ml with an MIC range of 1->128 g/ml, whereas that of cefatrizine-clavulanic acid was 2 g/ml with an MIC range of 0.5-32 g/ml. In vitro activity of cefatrizine-clavulanic acid was higher than that of cefatrizine. Conclusions : Improved in vitro activity of cefatrizine-clavulanic acid against isolates of E. coli and Klebsiella spp. from community-acquired urinary track infection suggested that the combination is useful for an empirical treatment of the infection. (Korean J Lab Med 2005; 25: 411-5) Key Words : Cefatrizine-clavulanic acid, Cefatrizine, Urinary track infection, Antimicrobial susceptibility 접수 : 2005년 9월 7일접수번호 : KJLM1882 수정본접수 : 2005년 11월 4일교신저자 : 이경원우 120-752 서울시서대문구신촌동 134 연세대학교의과대학진단검사의학과전화 : 02-2228-2446, Fax: 02-313-0908 E-mail : leekcp@yumc.yonsei.ac.kr * 본논문은 2003년도보건의료기술연구개발사업 (00-PJ1-PG4-PT01-0012) 연구비의지원으로이루어졌음. 서론 -lactam 항균제는그람음성간균감염증치료에가장흔히사용되는항균제중의한가지이다. -lactam 항균제에대한세균의내성기전중가장중요한것은 -lactamase 생성으로인한항균제의불활화이다 [1-3]. 최근분리되는그람음성간균중에는 -lactamase를생성하는균주가많아서 penicillin제와제1세대 411
412 노경호 염종화 용동은외 5 인 cephalosporin의유효성이현저히적어졌고 [4], 새로운약제가개발되어사용되고있다. -lactamase 생성세균감염에대처하기위해서는 -lactam 모핵에새로운작용기를도입하여 -lactamase에안정한제제를개발하거나, 기존 -lactam제와 -lactamase 저해제를복합하여사용하고있다 [5-7]. -lactamase 저해제는그자체의항균력은매우약하지만 - lactamase와비가역적으로결합하여효소의활성을억제한다 [8, 9]. 현재사용되는 -lactam과 -lactamase 저해제의병합제로는 amoxicillin 또는 ticarcillin과 clavulanic acid의복합제, cefoperazone 또는 ampicillin과 sulbactam의복합제, piperacillin과 tazobactam의복합제가있다 [8, 9]. Clavulanic acid는 Streptomyces clavuligerus로부터만든 -lactamase 저해제로 [10, 11], extended-spectrum -lactamase (ESBL) 를포함한여러종류의 class A -lactamase를억제한다 [2, 3, 7]. Cefatrizine은경구나비경구용 1세대 cephalosporin제로여러가지세균감염증치료에유용하게사용되어왔다 [12-14]. Cefatrizine-clavulanic acid ( 동아제약, 서울, 대한민국 ) 는제1세대경구용 cephalosporin인 cefatrizine과 clavulanic acid를병합한새로운제제이다. 이복합제는요로감염과호흡기감염에서주로분리되는병인균및 ESBL 등일부 -lactamase를생성하는세균에대한 MIC가낮으며동물실험을통해 ESBL 생성균감염에대한치료효과가있음이보고되었다 [15-18]. 그러나국내임상분리주에대한 cefatrizine-clavulanic acid의항균력에대한평가는그연구가적고, 요로감염증환자에서분리된임상분리주에대한항균력평가는더욱드물다. 본연구에서는요로감염증환자에서분리된그람음성간균에대한 cefatrizine-clavulanic acid의시험관내항균력을시험하였다. 재료및방법시험균주는 2003년 8-11월에세브란스병원에내원한외래및입원 2일내의환자중요로감염이의심되어세균배양이시행되고분리된총 204주즉, Escherichia coli 144주, Klebsiella pneumoniae 17주, Klebsiella oxytoca 13주, Enterobacter spp. 10주, Citrobacter spp. 8주, Proteus mirabilis 5주, Proteus vulgaris 1주, Providencia rettgeri 3주, Morganella morganii 2주, Serratia marcescens 1주를대상으로하였다. 항균제감수성은 NCCLS 한천희석법으로시험하였다 [19]. 시험항균제는 amoxicillin ( 근화제약, 서울, 대한민국 ), amikacin, cefatrizine 및 clavulanic acid ( 동아제약, 서울, 대한민국 ), cefaclor (Lilly, Indianapolis, USA), cefuroxime 및 tetracycline ( 종근당, 서울, 대한민국 ), cefoxitin (MSD, whitehouse station, USA), cefotaxime ( 한독, 서울, 대한민국 ), ceftazidime (Glaxo, Brentford, UK), gentamicin 및 cotrimoxazole ( 동화제약, 서울, 대한민국 ) 및 levofloxacin ( 제일약품, 서울, 대한민국 ) 을사용하 였다. 감수성시험용배지는 Mueller-Hinton 배지 (BBL, Cockeysville, MD, USA) 를사용하였다. 시험세균을 Steers replicator (Craft Machine Inc., Woodline, PA, USA) 를사용하여약 10 4 CFU 되게접종하여 35 에서 16-20시간배양하였다. MIC 시험시한개의집락이나연한증식은무시하였다. 정도관리를위해서는 E. coli ATCC 25922, Pseudomonas aeruginosa ATCC 27853의감수성을동시에시험하였다. 결과 E. coli에대한 amoxicillin의 MIC 50 와 MIC 90 는모두 >128 g/ ml이었으나, amoxicillin-clavulanic acid의 MIC 50 와 MIC 90 는각각 8 g/ml과 16 g/ml이었으며, 감수성률은 78% 이었다. Cefatrizine의 MIC 50 와MIC 90 는각각 2 g/ml과 16 g/ml이었고, cefaclor와 cefoxitin의 MIC 90 와비슷하였다. 반면 cefatrizineclavulanic acid의 MIC 50 와 MIC 90 는각각 1 g/ml과 4 g/ml 로, cefotaxime과 ceftazidime의 MIC보다는높았지만 cefaclor, cefuroxime 및 cefoxitin MIC의 1/2-1/4이었고, amikacin과비슷하였다. Gentamicin, tetracycline, cotrimoxazole 및 levofloxacin 에대한MIC 90 는 16 g/ml->128 g/ml이었으며, 감수성률은 54-81% 이었다. Klebsiella spp. 균종은 amoxicillin에자연내성이어서 MIC는 16 g/ml 이상이었으며 MIC 50 는 128 g/ml이었다. 그러나 amoxicillin-clavulanic acid의 MIC 90 는 8 g/ml이었고, 90% 의균주가감수성이었다. Cefatrizine의 MIC 90 는 4 g/ml로, cefuroxime 및 cefoxitin과같았으나, cefatrizine-clavulanic acid의 MIC 90 는 2 g/ml로낮았으며 cefaclor와 amikacin의 MIC 90 와같았다. Cefotaxime과 ceftazidime의 MIC 90 는각각 0.12 g/ml 과 1 g/ml이었고, 감수성율은 97% 로우수한항균력을보였다. 반면 gentamicin, tetracycline 및 cotrimoxazole의 MIC 90 는 128 g/ml->128 g/ml이었으며, 감수성률은 70-87% 로비교적낮았다. Enterobacter spp., Citrobacter spp., Proteus spp., P. rettgeri, M. morganii, S. marcescens 등의 Enterobacteriaceae 균종에대해서는 amikacin, gentamicin, cotrimoxazole, levofloxacin, 제 3세대 cephalosporin제등의항균력이비교적우수하여이들균종의감수성률은 80-100% 이었다. 반면에 amoxicillin, amoxicillinclavulanic acid, cefaclor, cefuroxime, cefatrizine, cefatrizineclavulanic acid, cefoxitin 등의항균력은비교적약하여 MIC 90 는 128 g/ml 이상이었고, amoxicillin-clavulanic acid, cefaclor, cefuroxime, cefoxitin의감수성률은 37-47% 이었다. Citrobacter freundii, Enterobacter aerogenes, P. rettgeri 균종중에는 cefatrizine-clavulanic acid의 MIC가 cefatrizine에비하여약간높은균주도있었다 (Table 1).
Cefatrizine-Clavulanic Acid 의시험관내항균력 413 Table 1. Activities of antimicrobial agents against strains of Enterobacteriaceae isolated from community-acquired urinary tract infections Organism (No. tested) Antimicrobial agent MIC ( g/ml) Range 50% 90% % of isolate S I R Escherichia coli (144) Amoxicillin 1->128 >128 >128 -* - - Amoxicillin-CA 1->128 8 16 78 17 5 Cefaclor 0.5->128 2 16 90 6 4 Cefuroxime 0.5->128 4 8 90 7 3 Cefatrizine 0.5->128 2 16 - - - Cefatrizine-CA 0.5-128 1 4 - - - Cefoxitin 0.5->128 4 16 88 3 9 Cefotaxime 0.008->128 0.06 0.25 99 0 1 Ceftazidime 0.008->128 0.25 0.5 99 0 1 Amikacin 0.5->128 2 4 99 0 1 Gentamicin 0.25->128 0.5 32 81 4 15 Tetracycline 0.5->128 4 >128 54 6 40 Cotrimoxazole 0.06->128 0.25 >128 58-42 Levofloxacin 0.015-64 0.06 16 74 2 24 Klebsiella spp. (30) Amoxicillin 16->128 128 >128 - - - Amoxicillin-CA 2-32 4 8 90 0 10 Cefaclor 0.5->128 1 2 90 0 10 Cefuroxime 2->128 4 4 90 3 7 Cefatrizine 1->128 1 4 - - - Cefatrizine-CA 0.5-32 1 2 - - - Cefoxitin 2->128 4 4 93 0 7 Cefotaxime 0.03-128 0.06 0.12 97 0 3 Ceftazidime 0.12->128 0.25 1 97 0 3 Amikacin 1->128 2 2 93 0 7 Gentamicin 0.5->128 0.5 128 87 0 13 Tetracycline 0.5->128 2 >128 70 3 27 Cotrimoxazole 0.06->128 0.5 >128 73-27 Levofloxacin 0.06-64 0.06 0.5 93 0 7 Other species of Amoxicillin 0.5->128 >128 >128 - - - Enterobacteriaceae (30) Amoxicillin-CA 0.5->128 64 128 30 0 70 Cefaclor 0.5->128 64 >128 37 0 63 Cefuroxime 0.12->128 8 >128 40 30 30 Cefatrizine 0.25->128 16 >128 - - - Cefatrizine-CA 0.25->128 32 128 - - - Cefoxitin 0.5->128 32 >128 37 7 57 Cefotaxime 0.008-128 0.12 32 80 13 7 Ceftazidime 0.008->128 0.5 64 83 0 17 Amikacin 0.5-16 2 8 100 0 0 Gentamicin 0.25->128 0.5 4 90 0 10 Tetracycline 1->128 4 128 50 7 43 Cotrimoxazole 0.06->128 0.25 >128 83-17 Levofloxacin 0.03-32 0.12 8 87 0 13 *-, Not applicable; Klebsiella pneumoniae (17), Klebsiella oxytoca (13); Enterobacter spp. (10), Citrobacter spp. (8), Proteus spp. (6), Providencia spp. (3), M. morganii (2), S. marcescens (1); Constant amount of clavulanic acid (4 g/ml) was used. The MICs were expressed as -lactam concentration only. Abbreviation: CA, clavulanic acid. 고 찰 Cefatrizine-clavulanic acid는 -lactam과 -lactamase 저해 제의새로운병합제로서, 임상검체에서분리된세균에대한시험 관내항균력에대한보고가있었다 [15-18]. 즉 methicillin 감수성 Staphylococcus aureus, Streptococcus pyogenes, Haemophilus influenzae 및 P. mirabilis에대해서는 cefatrizine의 MIC가낮아서 clavulanic acid와의병합제의 MIC가더저하되지는않았다 [18]. 그러나 Moraxella (Branhamella) catarrhalis, E. coli, K. pneumoniae, P. vulgaris와 Bacteroides fragilis에대해서는 clavulanic acid와병합함으로써항균력의상승을볼수있다고하였다 [18]. 그러므로 cefatrizine-clavulanic acid는요로감염이나호흡
414 노경호 염종화 용동은외 5 인 기감염의경험적치료항균제로유용할것으로보고되었다 [18]. 본연구에서는원외요로감염치료를위한 cefatrizine-clavulanic acid의유용성을평가하고자외래및입원후 2일이내의환자에서분리된균주로한정하여감수성시험을시행하였다. E. coli와 Klebsiella spp. 에대해서는 cefatrizine보다 cefatrizineclavulanic acid의 MIC가낮아서 MIC 90 가 E. coli에대해서 1/4, Klebsiella spp. 에는 1/2이었다. 국내에서분리되는 E. coli와 Klebsiella spp. 에서보고된주된 ESBL형은 TEM-52, SHV-12 및 SHV-2a형등이며, ESBL 생성균주는각각 9.1% 와 29.2% 에달하고그비율은매년증가하고있다 [20]. ESBL 생성주에의한패혈증및원내폐렴등의심각한감염증치료시시험관내항균력시험에서 3세대 cephalosporin에감수성또는중간을보여도실제치료에는 50% 이상이실패하였다는보고 [21] 가있다. 그러나요로감염은 -lactam 과 -lactamase 저해제의병합제로다른부위감염보다치료가잘된다는보고 [22] 가있는데이는요중항균제농도가다른조직중보다현저히높기때문이며 cephalosporin 단독사용보다 cefatrizine-clavulanic acid 병합제의치료효과도높을것으로생각된다. Enterobacter spp., Citrobacter spp., Proteus spp., P. rettgeri, M. morganii, S. marcescens는균종별시험수가적었기때문에부득이시험결과를함께분석하였다. 이들균주에대한 cefatrizineclavulanic acid의 MIC 범위와 MIC 90 은각각 0.25-128 g/ml 와 128 g/ml로 cefatrizine의 0.25-128 g/ml와 >128 g/ ml과비슷하였으나, 일부균주의경우 cefatrizine-clavulanic acid 의 MIC가 cefatrizine보다높았는데, 이는이들균주에서 clavulanic acid에의해염색체성 AmpC -lactamase 생성이유도되었기때문으로생각된다 [2]. 이들균종은원외감염균이기보다는원내감염을흔히일으키는것이므로진정한원외요로감염세균의 cefatrizine-clavulanic acid에대한임상효과는더욱좋을것으로생각된다. 결론적으로원외요로감염환자의요검체에서분리되는주요병원균인 E. coli와 Klebsiella spp. 에대한 cefatrizine-clavulanic acid의시험관내항균력은우수하여경험적요로감염치료항균제로유용할것으로판단된다. 요약배경 : 최근분리되는그람음성간균중에는 -lactamase를생성하는것이많아서 penicillin 제와제1세대 cephalosporin의유효성이현저히적어졌고, 새로운약제가개발되어사용되고있다. 본연구에서는제1세대경구용 cephalosporin인 cefatrizine과 clavulanic acid를병합한 cefatrizine-clavulanic acid 제의요검체분리주에대한시험관내항균력을평가하고자하였다. 방법 : 2003년세브란스병원에내원한외래및입원 2일이내환자의요검체에서분리된일련의 Enterobacteriaceae 균종을대 상으로 NCCLS 한천희석법에따라항균제감수성을시험하였다. 결과 : 총 204주중 Escherichia coli와 Klebsiella spp. 는각각 144주 (71%) 와 30주 (15%) 이었다. E. coli에대한 cefatrizine의 MIC 50 와MIC 90 는각각 2 g/ml과 16 g/ml이었고, cefaclor, cefoxitin의 MIC 90 과같았다. 반면 cefatrizine-clavulanic acid의 MIC 50 와 MIC 90 는각각 1 g/ml과 4 g/ml로 cefaclor, cefuroxime 및 cefoxitin MIC의 1/2-1/4이었고, amikacin과비슷하였다. Klebsiella spp. 에대한 cefatrizine과 cefatrizine-clavulanic acid의 MIC 90 는각각 4 g/ml와 2 g/ml이었고, MIC 범위는각각1->128 g/ml와 0.5-32 g/ml로 cefatrizine-clavulanic acid의항균력이좀더우수하였다. 결론 : Cefatrizine-clavulanic acid는원외요로감염환자에서분리되는주요병원균인 E. coli와 Klebsiella spp. 에대한시험관내항균력이우수하여요로감염증의경험적치료항균제로유용할것으로판단된다. 참고문헌 1. Noguchi JK and Gill MA. Sulbactam: a beta-lactamase inhibitor. Clin Pharm 1988; 7: 37-51. 2. Livermore DM. -lactamase-mediated resistance and opportunities for its control. J Antimicrob Chemother 1998; 41 (Suppl): 25-41. 3. Bush K, Jacoby GA, Medeiros AA. A functional classification scheme for -lactamases and its correlation with molecular structure. Antimicrob Agents Chemother 1995; 39: 1211-33. 4. Nordmann P. Trends in -lactam resistance among enterobacteriaceae. Clin Infect Dis 1998; 27 (Suppl): 100-6. 5. Yokota T, Sekiguchi R, Azuma E. Mode of inhibitory action of clavulanic acid against -lactamases and the synergistic antibacterial activity with -lactamase-susceptible -lactams. Chemotheraphy 1982; 40 (Suppl): 11-9. 6. Moellering RC. Meeting the challenges of -lactamases. J Antimicrob Chemother 1993; 31 (Suppl): 1-8. 7. Chong Y, Lee K, et al. eds. New antimicrobial resistance and mechanisms of bacteria. 1st ed, Seoul; Seoheung Publishing 2002: 102-20. 8. Sutherland R. -lactam/ -lactamase inhibitor combinations: Development, antibacterial activity and clinical applications. Infection 1995; 23: 191-200. 9. Yao JD and Moellering RC. Antibacterial agents. In: Murray PR, Baron EJ, Jorgensen JH, Pfaller MA, Yolken RH, eds. Manual of Clinical Microbiology. 8th ed. Washington, American Society for Microbiology 2003; 1039-73. 10. Brown AG, Butterworth D, Cole M, Hanscomb G, Hood JD, Reading C, et al. Naturally-occurring beta-lactamase inhibitors with antibacterial activity. J Antibiot 1976; 29: 668-9.
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