Staphylococcus Aureus and Vancomycin-Resistant Enterococcus Carriage in Peritoneal Dialysis Patients, and Evaluation of Invasive Infections Caused by These Microorganisms

Periton Diyalizi Hastalarında Staphylococcus Aureus ve Vankomisin Dirençli Enterokok Taşıyıcılığı ve Bu Mikroorğanizmaların Neden Olduğu İnvaziv Enfeksiyonların Değerlendirilmesi

Abstract

Objective: It is to investigate Staphylococcus aureus carrier state around nose and dialysis catheter and vancomycin resistant enterococcus (VRE) carrier state in rectum of continuous ambulatory peritoneal dialysis (CAPD) patients. Also, it is to evaluate the relations between S. aureus and VRE carriage and invasive infections caused these organisms. Methods: This study was performed by the Department of Clinical Bacteriology and Infectious Diseases in Medical School of Eski ehir Osmangazi University. Study was carried out with the patients receiving therapy between October 1, 2005 and March 31, 2006 in the dialysis unit of our hospital. Ethics Committee approval of our department was taken for the study. All patients were informed about the study, and they were included in the study by taking their written consents. The study group was comprised of the outpatients at the age of 18 and above that they were CAPD between the mentioned dates for the end-stage renal failure depending on various etiologies. Totally 50 patients were included in the study. Follow-up period was designated as 6 months and follow-up frequency was as once a month. The persons exiting from CAPD program without completing the surveillance period were followed-up until their exit date. Results: Twenty of the patients were women, 15 patients were men. Their ages were varied among 1870 years. Among all patients, the ratio of nose carriage were detected to be 17%, nose and catheter carriage were 6%, only catheter carriage were 6% and carriage for at least one region (nose or catheter) were 29%. Carriers were 30% of female patients and 27% of the males. Statistically no meaningful relation was found between carriage and gender (p=1.000). Average ages of the patients being and not being nose and/or catheter carriage were 47 and 48, respectively (p=0.792). When carriage ratios of diabetic and nondiabetic patients were compared, it was 0% in diabetic and 37% in non-diabetics (p=0.073). CAPD period was found to be approximately 18 months in carriers before they were included in the study, and it was found to be 23 months in non-carriers (p=0.570). Carriage among the patients receiving CAPD once day and four times day were 60% and 23%, respectively (p=0.l27). Carriage between hospitalized and non-hospitalized patients was detected 22% and 35%, respectively. No meaningful relation was detected between carriage and hospitalization (p=0.470). Statistically no meaningful difference was found between antibiotic usage and carriage (p=0.709). Statistically no meaningful relation was found between catheter insertion or change and carriage (p=0.688). However, statistically meaningful relation was found between catheter lost and carriage (p=0.001). The distribution of methicillin susceptibility of staphylococci strains was evaluated according to the carriage region. Methicillin-susceptible S. aureus (MSSA) reproduction was detected in all of the six patients being only nose carriers. MSSA reproduction was detected in the nose of one of the two patients being both nose and catheter carriers together. While in the other’s nose, both methicillin—resistant S. aureus (MRSA) and MSSA reproductions were detected in different times, and MSSA reproduction was detected around catheter as well. S. aureus strains reproducing in two catheter—carrier patients were susceptible to methicillin. Totally 19 peritoneal attack developed in 31% of the patients. In peritoneal attacks, S. aureus could not be isolated as an effector. The effector was coagulase negative staphylococci (CNS) in eight of the peritoneal attacks. Also, it was Corynebacterium spp. in one and Klebsiella oxytoca in one of them. While four of the peritonitis developed patients were carriers, seven of them were not. Conclusion: S. aureus carriage in the nose and/or around the catheter was found to be 29% of the patients receiving CAPD treatment. In carriers, number of MRSA was one, and MSSA was nine. Among the patients receiving CAPD, the number of VRE carrier in rectum was found to be low (2%). The effectors in peritonitis were found to be eigth CNS, one Corynebacterium spp. and one K. oxytoca. Being S. aureus carriage was found not to be risk factor in the invasive infection development. Among the patients that lost their catheter, the number of S. aureus carrier was found to be high. If peritonitis causes catheter lost, this may be related to carrying S. aureus. For this group of patients, there need to be comparative studies including much more patients in order to determine the risk factors.

Özet

Amaç: Sürekli ayaktan periton diyalizi (SAPD) tedavisi alan hastaların burun ve diyaliz kateteri çevresinde Staphylococcus aureus ve rektumda vankomisin dirençli enterokok (VRE) ta ıyıcılık durumunu ara tırmaktır. Ayrıca, ta ıyıcılarda S. aureus ve VRE ta ıyıcılı ı ile bunların neden oldu u invaziv enfeksiyonların ili kilerini de erlendirmektir. Gereç ve yöntem: Bu çalı ma, Eski ehir Osmangazi Üniversitesi Tıp Fakültesi Klinik Bakteriyoloji ve Enfeksiyon Hastalıkları Anabilim Dalı tarafından yürütüldü. Çalı ma, 01 Ekim 2005-31 Mart 2006 tarihleri arasında hastanemiz diyaliz ünitesinde tedavi alan hastalar üzerinde yapıldı. Söz konusu tarihler arasında, çe itli etiyolojilere ba lı son dönem böbrek yetmezli i için SAPD tedavisi alan ve fakültemiz Nefroloji Bilim Dalı tarafından takip edilen 18 ya ve üzeri hastalar çalı ma grubunu olu turdu. Toplam 50 hasta çalı maya alındı. zlem süresi 6 ay, izlem sıklı ı ayda bir kez olarak belirlendi. Bulgular: Hastaların 20'si kadın, 15'i erkekti. Ya ları 18-70 arasında de i mekteydi. Sadece burun ta ıyıcılı ı %17, sadece kateter ta ıyıcılı ı %6, burun ve kateter ta ıyıcılı ı birlikte %6, en az bir bölgede (burun veya kateter) ta ıyıcılık oranı hastaların %29'unda saptandı. Kadınların %30'unda ve erkeklerin %27'sinde ta ıyıcılık belirlendi. Ta ıyıcılık ile cinsiyet arasında anlamlı bir ili ki yoktu (p=1.000). Burun ve/veya kateter ta ıyıcısı olanlarla olmayanların ya ortalaması sırasıyla 47 ve 48 bulundu (p=0.792). Diyabetik hastalarda ta ıyıcılık tespit edilmezken diyabetik olmayanlarda %37 ta ıyıcılık görüldü (p=0.073). Ta ıyıcılar çalı maya dâhil edilmeden önceki SAPD süresi ortalama 18 ay, ta ıyıcı olmayanlarda 23 ay bulundu (p=0.570). Günde 1 kez ile 4 kez SAPD alanların ta ıyıcılıkları sırasıyla %60 ve %23 saptandı (p=0.127). Hastanede yatan ve yatmayan hastalarda ta ıyıcılık oranları sırasıyla %22 ve %35 bulundu. Ta ıyıcılık ile hastanede yatma arasında anlamlı ili ki yoktu (p=0.470). Antibiyotik kullanımı ile ta ıyıcılık arasında anlamlı bir fark bulunmadı (p=0.709). Kateter takılması ya da de i tirilmesi ile ta ıyıcılık arasında da anlamlı ili ki yoktu (p=0.688). Kateter kaybı ile ta ıyıcılık arasında ise istatistiksel olarak anlamlı bir ili ki tespit edildi (p=0.001). Sadece burun ta ıyıcısı olan 6 hastada metisilin duyarlı S. aureus (MSSA) üredi. Burun ve kateter ta ıyıcılı ının birlikte oldu u iki hastadan birinin burnunda MSSA, di erinde ise burnunda farklı zamanlarda hem MSSA Sonuç: SAPD tedavisi alan hastaların burun ve/veya kateter kuşatan deri çevresinde %29 S. aureus taşıyıcılığı bulundu. Taşıyıcılarda MRSA sayısı iken MSSA sayısı olarak saptandı. Hastaların rektumunda VRE taşıyıcılığı oldukça düşüktü (%2). Peritonit gelişen hastalarda etken olarak 8'de KNS, l'de Corynebacterium spp. ve bir K. oxytoca izole edildi. İnvaziv infeksiyon gelişmesinde S. aureus taşıyıcılığı bir risk faktörü olarak bulunmadı. Kateter kaybına uğrayan hastalarda S. aureus taşıyıcılığı yüksek bulundu. Eğer peritonit, kateter kaybına neden oluyorsa bu S. aureus taşıyıcılığı ile ilişkili olabilir. Bu grup hastalarda risk faktörlerini belirlemek için daha fazla sayıda hasta içeren karşılaştırmalı çalışmalara ihtiyaç vardır.