Acinetobacter svarba klinikinėje praktikoje
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1 Acinetobacter svarba klinikinėje praktikoje Jolita Mackevičiūtė Higienos institutas Mokslinė praktinė konferencija Antibiotikų vartojimo ir antimikrobinio atsparumo tendencijos Panevėžys
2 Turinys Acinetobacter spp. epidemiologiniai aspektai Acinetobacter spp. klinikinė reikšmė Atsparumo ir infekcijos rizikos veiksniai Grėsmė visuomenės sveikatai Epidemiologinė situacija pasaulyje ir Lietuvoje Išvados 2
3 Acinetobacter spp. epidemiologiniai aspektai (I) Nejudri, aerobinė, turinti kapsulę, gramneigiama bakterija Prieš keletą dešimtmečių ~ sąlyginis patogenas Šiuo metu pasaulyje svarbus, problematiškas, dominuojantis su sveikatos priežiūros įstaigų veikla (SSPĮV) susijusių infekcijų sukėlėjas Multirezistentiškas patogenas (būdinga visi 3 atsparumo laipsniai ang. MDR, XDR, ir PDR )
4 Acinetobacter spp. epidemiologiniai aspektai (II) Infekcijos šaltinis (rezervuaras): - Sveikų žmonių (25%), pacientų, medicinos personalo darbuotojų, gyvūnų oda Dažniausios medicinos personalo ant odos nešiojamos gramneigiamos bakterijos! - Negyvi aplinkos paviršiai: Vanduo, dirvožemis Ligoninės aplinka (įvairi medicinos įranga, kt. aplinkos daiktai ir paviršiai)
5 Acinetobacter spp. epidemiologiniai aspektai (III) Acinetobacter baumanii 80% visų Acinetobacter sąlygotų SSPĮVSI Atspari išdžiuvimui išlieka ilgai aplinkoje Sąlygojanti infekcijos protrūkius - ypač reanimacijos intensyvios terapijos skyriuose (RITS) *Protrūkių priežastys: - Ligoninės ir paciento aplinkos užterštumas (20/27 protrūkių tyrimai) - Medicinos darbuotojų rankų kontaminacija * Souli M, Galani I, Giamarellou H. Emergence of extensively drug-resistant and pandrug-resistant Gram-negative bacilli in Europe. Euro Surveill 2008;13(47). pii:
6 Klinikinė reikšmė (I) Dominuojantis SSPĮV susijusių infekcijų sukėlėjas RITS, dažniausia sukelia : - Pneumonijas susijusias su DPV - Kraujo infekcijas Kitos infekcijos - Šlapimo takų - Žaizdų - Minkštųjų audinių - Endokarditas - Meningitas
7 Klinikinė reikšmė (II) Acinetobacter baumanii infekcija susijusi : Mirštamumas (26-68%) Hospitalizacijos trukmė (ik 18 dienų) - Hospitalizacija RITS (iki 6 dienų) Dirbtinė plaučių ventiliacija (iki 5 dienų) Išlaidos (ekonominė našta) Souli M, Galani I, Giamarellou H. Emergence of extensively drug-resistant and pan drug-resistant Gram-negative bacilli in Europe. Euro Surveill 2008;13(47). pii: L.L. Maragakis, Trish M. Perl. Acinetobacter baumanii:epidemiology, Antimicrobial Resistance, and Treatment Options. Clinical Infectious Diseases 2008;46:
8 Klinikinė reikšmė III ATSPARUMO GRĖSMĖ Mažiausia trijų skirtingų klasių antibiotikai NEBEVEIKSMINGI gydant atsparių Acinetobacter padermių sukeltas infekcijas
9 Atsparumo rizikos veiksniai m. 20 Atvejo-kontrolės tyrimai (PubMed) NERACIONALUS ANTIBIOTIKŲ VARTOJIMAS!! Dažniausi antibiotikai susiję su Acinetobacter spp. atsparumu: Karbapenemai III kartos cefalosporinai Kiti (fluorochinolonai, aminoglikozidai, metranidazolas) *Souli M, Galani I, Giamarellou H. Emergence of extensively drug-resistant and pandrug-resistant Gram-negative bacilli in Europe. Euro Surveill 2008;13(47). pii:
10 Acinetobacter infekcijos rizikos veiksniai Dažniausias dirbtinė plaučių ventiliacija (25 % visų atliktų tyrimų) Kiti rizikos veiksniai : Hospitalizacija ir hospitalizacijos trukmė RITS Chirurginiai skyriai (žaizdų, nudegimų gydymas) Ankstesnė antibiotikoterapija Pastarosios operacijos, invazinės procedūros Ligos sunkumo laipsnis Gretutinės lėtinės ligos, diabetas, imunodeficitiniai susirgimai Dažna ekspozicija su sergančiu, kolonizuotu pacientu, medicinos personalu
11 Grėsmė visuomenės sveikatai JAV Per metus Acinetobacter infekcijos atvejų ~ 2% visų SSPĮVSI Su sveikatos priežiūros įstaigų veikla susijusios infekcijos Mirties atvejai Dauginioatsparumo Acinetobacter 7,300 (63%) 500 Centers for Disease Control and Prevention, Antibiotic resistance threats in the United States,
12 Grėsmė visuomenės sveikatai Europoje Per metus Acinetobacter infekcijos atvejų ~ 3.6% visų SSPĮVSI Su sveikatos priežiūros įstaigų veikla susijusios infekcijos Dauginio atsparumo Acinetobacter 81.2% Point prevalence survey of healthcare associated infektions and antimicrobial use in European acute care hospitals. Surveillance report
13 Acinetobacter epidemiologinė situacija Lietuvoje 13
14 Su sveikatos priežiūros įstaigų veikla susijusių infekcijų ir jų rizikos veiksnių paplitimas ( m.) 14
15 Dažniausi SSPĮVSI sukėlėjai ( m.) (%) Acinetobacter spp Klebsiella spp Enterococcus spp Pseudomonas aeruginosa Staphylococcus aureus Escherichia coli *SSPĮVSI *SSPĮVSI Su sveikatos priežiūros įstaigų veikla susijusios infekcijos 15
16 Operacinių žaizdų infekcijų (OŽI) epidemiologinė priežiūra chirurgijos skyriuose ( m.) 16
17 S k a ič iu s Pav. Išskirtų Acinetobacter spp. skaičius tarp registruotų OŽI( m.) O p e r a c in ių ž a i z d ų in f e k c ijo s A c in e t o b a c t e r s p p M e ta i
18 Acinetobacter spp. skaičius pagal operacijos tipą ( m.) Operacijos tipas Metai Viso Koronarinių arterijų šuntavimas Storosios žarnos operacijos Cholecistektomija Ortopėdinės operacijos klubo sąnario protezavimas kelio sąnario protezavimas Apendektomija Cezario pjūvio operacijos Kirkšnies išvaržos operacijos Viso x 1 x x 2 x 1 x 3 x x
19 Su sveikatos priežiūros įstaigų veikla susijusių infekcijų epidemiologinė priežiūra reanimacijos-intensyvios terapijos skyriuose (RITS) ( m.) 19
20 Dešimt dažniausių sukėlėjų, sąlygojusių SSPĮV susijusias infekcijas, RITS, m Procentai Acinetobacter spp Klebsiella spp. 4.4** 3.0** Enterococcus spp Pseudomonas aeruginosa Staphylococcus aureus * Escherichia coli Enterobacter spp Candida spp Seratia spp Haemophilus spp *Staphylococcus spp. **Klebsiella pneumonia Iš viso tirta
21 Acinetobacter spp. sukeltos SSPĮV susijusios infekcijos, RITS, ( m.) Procentai Pneumonija Kraujo infekcijos Šlapimo takų infekcijos OŽI Metai 21
22 Sveikatos priežiūros įstaigų Mikrobiologijos laboratorijų pilotinio tyrimo duomenys (n=3), Vilnius,
23 Acinetobacter spp. išskyrimas pagal skyrius, 2012 m. S kyriai RITS Chirurginiai Urologijos Terapiniai Hem atologijos / onkologijos Vaikų / naujagimių R ITS Infekcinių ligų Vaikų / naujagimių Akušeriniai / ginekologiniai S kaičiu s Viso 387
24 Acinetobacter spp. išskyrimas iš klinikinės medžiagos 2012 m. Tiriamoji medžiaga Šlapimas Žaizdų sekretas Apatinių kvėpavimo takų sekretas Kraujas Total Skaičius
25 Acinetobacter spp. atsparumas antimikrobiniams vaistams kraujo pasėliuose, 2012 m. Procentai Trimetoprimas /Sulfametoksazolis (32) Amikacinas Ciprofloksacinas Meropenemas / (35) (34) Imipenemas (35) Gentamicinas Kolistinas (35) (32) * Skliausteliuose viso tirta ėminių 25
26 Acinetobacter spp. atsparumas antimikrobiniams vaistams šlapimo pasėliuose, 2012 m. 100 Procentai Trimetoprimas Meropenemas / /Sulfametoksazolis Imipenemas (111) (107) Ciprofloksacinas Amikacinas Gentamicinas Kolistinas (118) (111) (118) (101) * Skliausteliuose viso tirta ėminių 26
27 Acinetobacter spp. atsparumas antimikrobiniams vaistams iš apatinių kvėpavimo takų tiriamosios medžiagos, 2012 m. 100 Procentai T rimetoprimas Amikacinas Ciprofloksacinas Gentamicinas M eropene mas / /Sulfametoksazolis (83) (84) (85) Imipenemas (58) (85) * Sk liausteliuose viso tirta ėm inių Kolistinas (64) 27
28 Acinetobacter spp. atsparumas antimikrobiniams vaistams iš žaizdų tiriamosios medžiagos, 2012 m. 100 Procentai C iprofloksacinas Amikacinas G e ntamicinas T rime toprimas M e ropene mas / /Sulfame toksazolis Imipene mas (111) (74) (75) (93) * Sk liausteliuose viso tirta ėm inių (111) Kolistinas (97) 28
29 Išvados (I) Acinetobacter - rimta grėsmė visuomenės sveikatai: Vienas iš dažniausių SSPĮV susijusių infekcijų sukėlėjų Dažniausiai sukeliantis pneumonijas RITS Sąlygoja didelį mirštamumą (dažniausia kritinės būklės pacientams) Sąlygoja ilgesnę hospitalizacijos trukmę Pasižymi dauginiu ir visišku atsparumu antimikrobiniams preparatams Acinetobacter infekcijos terapinės galimybės tampa ribotos
30 Išvados (II) Acinetobacter sunku valdyti, bet įmanoma! - Griežta SSPĮV susijusių infekcijų kontrolė (valdymas) Tinkama Rankų Higiena kertinis akmuo! - Antibiotikų valdymo politika Tinkamas skyrimas! Racionalus vartojimas!
31 Dėkoju už dėmesį!.sėkmės darbuose! 31
μ gyra parc Escherichia coli Klebsiella pneumoniae Pseudomonas aeruginosa E. coli gyra E. coli parc gyra parc gyra Escherichia coli E. coli E.
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