Razi Journal of Medical Sciences

fa مقایسه درمان برپایه کلستین با درمان بر پایه آمپی سیلین سولباکتام در آسینتوباکتر مقاوم به کارباپنم در پنومونی ناشی از ونتیلاتور Ampicillin-sulbactam base compared Colistin Base for the treatment of acintobacter resistant to carbapenems in ventilator associated pneumonia بیماریهای عفونی Infectious Disease پژوهشي Research زمینه و هدف: گونه‌های آسینتوباکتر پاتوژن‌های مهم بیمارستانی هستند و افزایش شیوع مقاومت چند دارویی به خصوص نسبت به کارباپنم‌ها در گونه‌های آسینتوباکتر رو به افزایش است. هدف از مطالعه فوق مقایسه درمان برپایه کلستین با درمان بر پایه آمپی سیلین سولباکتام در آسینتوباکتر مقاوم به کارباپنم‌ها در پنومونی ناشی از ونتیلاتور است. روش کار: در این مطالعه کارآزمایی بالینی دوسوکور، 43 بیمار مبتلا به پنومونی ناشی از ونتیلاتور با آسینتوباکتر تولید کننده کارباپنم در 2 گروه درمانی آمپی سیلین سولباکتام+ کارباپنم  و کلستین + کارباپنم بررسی شدند. بیماران در ابتدا و انتهای درمان از نظر تعداد گلبول سفید و ESR و کشت خلط و مرگ و میر بررسی شدند. داده‌ها توسط نرم افزار SPSS 20    آنالیز گردید. یافته‌ها: تعداد گلبول‌های سفید و میزان سدیمانتاسیون خون در گروه کلستین به همراه کارباپنم به میزان بیشتری کاهش یافته بود و اختلاف آماری معنی داری در دو گروه مشاهده شد (05/0 p<). در گروه کلستین + کارباپنم در انتهای مطالعه 23 مورد کشت خلط از نظر آسینتوباکتر منفی بود. بیمارانی که بر پایه آمپی سولباکتام درمان شدند، تنها یک مورد کشت خلط از نظر آسینتوباکتر منفی بود. نتیجه‌گیری: استفاده از کلستین +کارباپنم سبب بهبود پاسخ بالینی و آزمایشگاهی بیماران می‌گردد و لذا در  بیماران با پنومونی ناشی از ونتیلاتور با آسینتوباکتر مقاوم به کارباپنم به عنوان درمان ارجح توصیه می‌شود.   Background: Acinetobacter baumannii (A.  baumanni) is one of the most important pathogens of Ventilator- associated Pneumonia in hospitals. Ventilator-associated pneumonia usually develops after more than 48 hours of tracheal intubation and mechanical ventilation. Prevalence of Multidrug-resistant (MDR) in Acinetobacter baumannii species is increasing. This organism can cause severe infections in hospital settings, especially in the ICU. In the past, carbapenems such as meropenem and imipenem have been used as the drug of choice in the treatment of multidrug-resistant Acinetobacter infections. Carbapenem resistance is currently increasing. Despite numerous studies to treat ventilator-associated pneumonia caused by Carbapenem- resistant A.  baumanni, the best drug choice for the treatment of this pneumonia remains unclear. Although some studies suggest Colistin as a first-line drug choice for critically ill patients with ventilator-associated pneumonia, the results of a systematic review study in 2017 showed that monotherapy with sulbactam in the treatment of pneumonia caused by drug-resistant Acinetobacter is preferable to treatment with intravenous colistin. Researchers have recommended clinical trials to confirm the findings in this pneumonia. Therefore, the purpose of this study was to compare colistin based vs. Ampicillin-Sulbactam based therapy in carbapenem-resistant A.  baumanni ventilator- associated pneumonia. Methods: In this double-blind clinical trial study, 43 patients with ventilator-associated pneumonia who were admitted to the ICU of Valiasr Hospital in Arak, Iran, were included in the study and were assessed in two groups: colistin based vs. Ampicillin-Sulbactam based. Patients were evaluated at baseline and at the end of treatment for white blood cell count, ESR, and sputum culture and mortality. Inclusion criteria included age over 16 years and ventilator-induced pneumonia with carbapenem-resistant A.  baumanni. Exclusion criteria included discontinuation of treatment and patient dissatisfaction to continue the study. Lower Respiratory Secretion was collected from these patients and sent to the laboratory. Isolation of bacteria was performed according to the standard bacteriological method and then using isolated biochemical methods, the isolated bacteria were identified up to the species. E-test was used to determine the lowest growth inhibitory concentration (MIC) to colistin and ampicillin sulbactam. The sample size was 33 patients in each group. There were 33 patients in the Colistin group. In the ampicillin-sulbactam group, 10 patients and 20 laboratory samples with ampicillin-sulbactam discs were also performed by antibiogram method. Laboratory sputum culture was used because antibiotic resistance was observed in the first 10 patients in the ampicillin-sulbactam group and there was no complete recovery and therefore due to concern for the lives of patients; The rest of the samples were performed in vitro. Patients were evaluated at the beginning and end of treatment on day 14. It should be noted that in order to double-blinded study, the patient and the data analyzer did not know about grouping. Data were analyzed by SPSS 20 software using descriptive statistics, t-test and chi-square. The normality of quantitative data distribution was checked by Kolmogorov-Smirnov test. The code of ethics of this dissertation was IR.ARAKMU.REC.1397.89. The registration code in Iran Clinical Trial Center for the above dissertation was IRCT20141209020258N126. Results: In this double-blind clinical trial study, 33 patients in the colistin group and 10 patients and 20 sputum culture samples in the ampicillin-sulbactam group were studied. The mean ± standard deviation of age of 43 patients was 48.23±16.85 years. The minimum age was 19 years and the maximum age was 85 years. In the cholistin + carbapenem group, out of 33 patients who were initially admitted to the study, 3 died before the end of the study and in the ampicillin-sulbactam group, out of 10 patients admitted to the study, 2 died before the end of the study.  The number of WBC and the rate of ESR in the colistin + carbapenem group were decreased significantly (p<0.05) and 23 cases of sputum culture were negative for acinetobacter at the end of the study. in the colistin based group on day 14 of treatment, only 2 patients had higher than normal WBC counts and 24 cases had normalized chest X-rays. In the ampi-sulbactam+carbapenem group, at the end of treatment, 3 patients had normal WBC counts. Only one sputum culture was negative and 1 case had normal chest x-ray at the end of study. In 20 sputum culture samples that were examined in vitro, only two samples were sensitive to ampicillin-sulbactam and 18 cases were resistant to ampicillin-sulbactam. Conclusion: The use of colistin+carbapenem improves clinical and laboratory response of patients. Therefore colistin-based therapy for the treatment of Carbapenem- resistant A.  baumanni ventilator-associated pneumonia is recommended.. آسینتوباکتر بومانی, کلستین, آمپی_سولباکتام, پنومونی ناشی از ونتیلاتور, آسینتوباکتر بومانی مقاوم به کارباپنم Acinetobacter baumanii, Colestin, Ampicilin-Sulbactam, Ventilator-associated Pneumonia , Carbapenem Resistant A. baumanii 188 196 http://rjms.iums.ac.ir/browse.php?a_code=A-10-2782-4&slc_lang=fa&sid=1 Masoomeh Sofian معصومه صوفیان ma_sofian@yahoo.com 3900319475328460053421 3900319475328460053421 No Department of Infectious Diseases, Infectious Diseases Research Center (IDRC), Arak University of Medical Sciences, Arak, Iran داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﮑﯽ اراک، اراک ، ایران reza jafari رضا جعفری dr.jafari59@gmail.com 3900319475328460053422 3900319475328460053422 No Department of Infectious Diseases, Infectious Diseases Research Center (IDRC), Arak University of Medical Sciences, Arak, Iran گروه بیماری‌های عفونی، مرکز تحقیقات بیماری‌های عفونی، داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﮑﯽ اراک، اراک ، ایران Ehsanollah Ghaznavi-Rad احسان اله غزنوی راد ghaznaviehs@yahoo.com 3900319475328460053423 3900319475328460053423 No Department of Hematology, School of Allied Medical Sciences Infectious Diseases Research Center Arak University of Medical Sciences گروه هماتولوژی، دانشکده پیراپزشکی مرکز تحقیقات بیماری‌های عفونی دانشگاه علوم پزشکی اراک Amitisi Ramezani آمیتیس رمضانی ramezani.a@yahoo.com 3900319475328460053424 3900319475328460053424 No Department of Clinical Research, Pasteur Institute of Iran گروه تحقیقات بالینی، انستیتو پاستور ،تهران، ایران Nader zarinfar نادر زرین فر nzarinfar@yahoo.com 3900319475328460053425 3900319475328460053425 No Department of Infectious Disease, School of Medicine Infectious Diseases Research Center Amiralmomenin Hospital, Valiasr Hospital Arak University of Medical Sciences گروه بیماری‌های عفونی،|داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﮑﯽاراک، اراک، ایران pegah mohaghegh پگاه محقق pmohaghegh@arakmu.ac.ir 3900319475328460053426 3900319475328460053426 Yes , Department of community Medicine, School of Medicine, Arak University of Medical sciences, Arak, Iran داﻧﺸﮑﺪه ﭘﺰﺷﮑﯽ، داﻧﺸﮕﺎهﻋﻠﻮم ﭘﺰﺷﮑﯽاراک، اراک، ایﺮان