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임상미생물검사 신빙도 조사 결과보고(2000)

임상미생물검사 신빙도 조사 결과보고(2000). 대한임상검사정도관리협회 임상미생물분과위원회 김의종(집필대표), 강정옥, 김미나, 김민중, 김성일, 이경원, 이도현, 이장호, 이남용, 이창규, 신종희, 장철훈, 최혜심. Table 1. Microorganisms distributed for External Quality Assessment of Clinical Microbiology Laboratory in 2000. Specimen number. Trial. Microorganism.

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임상미생물검사 신빙도 조사 결과보고(2000)

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  1. 임상미생물검사 신빙도 조사 결과보고(2000) 대한임상검사정도관리협회 임상미생물분과위원회 김의종(집필대표), 강정옥, 김미나, 김민중, 김성일, 이경원, 이도현, 이장호, 이남용, 이창규, 신종희, 장철훈, 최혜심

  2. Table 1. Microorganisms distributed for External Quality Assessment of Clinical Microbiology Laboratory in 2000 Specimen number Trial Microorganism Source MB0001 MB0002 MB0003 MB0004 MB0005 Klebsiella oxytoca Enterococcus faecalis Salmonella spp. Group D Proteus vulgaris Staphylococcus aureus Clinical isolate ATCC 29212 Clinical isolate ATCC 49132 ATCC 25923 I MB0006 MB0007 MB0008 MB0009 MB0010 Staphylococcus aureus Enterococcus faecalis E. coli Pseudomonas aeruginosa Klebsiella pneumoniae ATCC 25923 ATCC 29212 ATCC 25922 ATCC 27853 ATCC 700603 II

  3. Table 2. Performance on the identification of microorganisms distributed for External Quality Assessment of Clinical Microbiology Laboratory in 2000 No. of laboratories indicated level of performance Specimen Number No. of laboratories Microorganisms Not acceptable Good Acceptable MB0001 MB0002 MB0003 MB0004 MB0005 MB0006 MB0007 MB0008 MB0009 MB0010 Klebsiella oxytoca Enterococcus faecalis Salmonella spp. Group D Proteus vulgaris Staphylococcus aureus Staphylococcus aureus Enterococcus faecalis E. coli Pseudomonas aeruginosa Klebsiella pneumoniae 209 154 151 209 213 217 175 223 213 222 - 40 47 1 - - 35 - 9 1 8 23 19 7 4 8 15 2 3 2 217 217 217 217 217 225 225 225 225 225

  4. Not acceptable for the identification • Enterococcus faecalis • MB0002 10.6% (23/217) • MB0007 6.7% (15/225) • Salmonella spp. Group D 8.8% (19/217)

  5. Catalase-negative, gram-positive cocci with bile-esculin-positive Enterococcus Group D streptococci 6.5% NaCl broth Growth No growth PYR test + - PYR: L-pyrrolidonyl-b-naphthylamide Group D streptococci: S. bovis, S. equinus

  6. Enterococcus spp. Motility Yellow colony E. faecalis - - E. faecium - - E. gallinarum + - E. casseliflavus + +

  7. Salmonella spp. MacConkey agar SS agar XLD agar TSI agar: K/Ag+, K/Ag- Lysine iron agar: K/K+ TSI LIA

  8. Table 3-1. Performance on the disk-diffusion antibiotic susceptibility tests (mm) of microorganisms distributed for External Quality Assessment of Clinical Microbiology Laboratory in 2000 Not Acceptable Specimen number Microorganisms and antibiotics No. of lab less than lower limit more than upper limit Good MB0001 K. oxytoca Cephalothin 153 145(94.8%) NA* 8(5.2%) Cefotaxime 146 94(64.4%) 52(35.6%) NA MB0002 E. faecalis Ampicillin 170 165(97.1%) 5(2.9%) NA Vancomycin 170 105(61.8%) 65(38.2%) NA MB0003 Salmonella Group D Ampicillin 170 168(98.8%) 2(1.2%) NA SXT 131 131(100%) 0 NA MB0004 P. vulgaris Cephalothin 154 93(60.4%) NA 61(39.6%) Gentamicin 174 172(98.8%) 2(1.2%) NA *NA: not applicable

  9. Salmonella, Shigella • 항생제 감수성 검사 • Ampicillin • Ciprofloxacin • Trimethoprim/sulfamethoxazole • 1세대, 2세대 세팔로스포린은 검사하지 않는다. • 장외에서 분리된 Salmonella • Chloramphenicol, cefotaxime 추가

  10. Salmonella, Shigella • 3세대 세팔로스포린 (ceftriaxone, cefotaxime, cefoperazone 등)에서 중간 (intermediate) 또는 내성으로 나오면, ESBL test를 실시한다. • ESBL: Extended-spectrum -lactamase • 거의 모든 세팔로스포린으로 치료되지 않는다. • 검사에서 감수성으로 나와도 내성으로 보고한다. • ESBL-Shigella: 세계 최초로 출현!!!!!! • ESBL-Salmonella: 간혹 분리되고 있음

  11. Table 3-2. Performance on the disk-diffusion antibiotic susceptibility tests (mm) of microorganisms distributed for External Quality Assessment of Clinical Microbiology Laboratory in 2000 Not Acceptable Specimen number Microorganisms and antibiotics No. of lab less than lower limit more than upper limit Good MB0005 S. aureus Oxacillin 170 139(81.8%) 15(8.8%) 16(9.4%) Vancomycin 175 104(59.4%) 67(38.3%) 4(2.3%) MB0006 S. aureus Oxacillin 172 151(87.8%) 15(8.7%) 6(3.5%) Vancomycin 178 126(70.7%) 51(28.7%) 1(0.6%) MB0007 E. faecalis Ampicillin 172 169(98.3%) 3(1.7%) NA Vancomycin 173 117(67.6%) 56(32.4%) NA *NA: not applicable

  12. S. aureus (ATCC 25923), Vancomycin Unacceptable: MB0005 - 38.3% (67/175) MB0006 - 28.7% (51/178)

  13. Staphylococcus spp.에서 vancomycin disk 15 mm 이상이어야 감수성으로 판정하고, 14 mm이하이면 반드시 최소억제농도를 측정하여 4 g/mL이하이면 감수성이며, 4 g/mL보다 크면 내성을 의심해야 한다.

  14. Table 3-3. Performance on the disk-diffusion antibiotic susceptibility tests (mm) of microorganisms distributed for External Quality Assessment of Clinical Microbiology Laboratory in 2000 Not Acceptable Specimen number Microorganisms and antibiotics No. of lab less than lower limit more than upper limit Good MB0008 E. coli Ampicillin 172 151(87.7%) 13(7.6%) 8(4.7%) Gentamicin 179 154(86.1%) 11(6.1%) 14(7.8%) MB0009 P. aeruginosa Piperacillin 136 125(91.9%) 11(8.1%) 0 Gentamicin 178 142(79.8%) 2(1.1%) 34(19.1%) MB0010 K. pneumoniae Cefotaxime 148 136(91.8%) 10(6.8%) 2(1.4%) Imipenem 156 154(98.7%) 2(1.3%) 0

  15. Table 4-1. Performance on the automated or Etest antibiotic susceptibility tests ( g/ml) of bacteria distributed for External Quality Assessment of Clinical Microbiology Laboratory in 2000 Not Acceptable Specimen number Microorganisms and antibiotics No. of lab less than lower limit more than upper limit Good MB0001 K. oxytoca Cephalothin 64 61(95.3%) 3(4.7%) NA* Cefotaxime 62 60(96.8%) NA 2(3.2%) MB0002 E. faecalis Ampicillin 61 59(96.7%) 0 2(3.3%) Vancomycin 64 63(98.4%) 0 1(1.6%) MB0003 Salmonella Group D Ampicillin 64 64(100%) 0 NA SXT 60 60(100%) 0 NA MB0004 P. vulgaris Cephalothin 59 35(59.3%) 24(40.7%) NA Gentamicin 66 65(98.5%) NA 1(1.5%) *NA: not applicable

  16. Table 4-2. Performance on the automated or Etest antibiotic susceptibility tests ( g/ml) of bacteria distributed for External Quality Assessment of Clinical Microbiology Laboratory in 2000 Not Acceptable Specimen number Microorganisms and antibiotics No. of lab less than lower limit more than upper limit Good MB0005 S. aureus Oxacillin 59 59(100%) 0 0 Vancomycin 65 65(100%) 0 0 MB0006 S. aureus Oxacillin 63 62(98.4%) 0 1(1.6%) Vancomycin 65 64(98.5%) 0 1(1.5%) MB0007 E. faecalis Ampicillin 67 63(96.0%) 0 4(6.0%) Vancomycin 70 68(97.1%) 0 2(2.9%) *NA: not applicable

  17. Table 4-3. Performance on the automated or Etest antibiotic susceptibility tests ( g/ml) of bacteria distributed for External Quality Assessment of Clinical Microbiology Laboratory in 2000 Not Acceptable Specimen number Microorganisms and antibiotics No. of lab less than lower limit more than upper limit Good MB0008 E. coli Ampicillin 66 64(97.0%) 0 2(3.0%) Gentamicin 60 54(90.0%) 0 6(10.0%) MB0009 P. aeruginosa Piperacillin 65 62(95.4%) 0 3(4.6%) Gentamicin 65 59(90.8%) 0 6(9.2%) MB0010 K. pneumoniae Cefotaxime 65 65(100%) 0 0 Imipenem 67 67(100%) 0 0

  18. E. faecalis (ATCC 29212), Vancomycin Unacceptable: MB0002 - 38.2% (65/170) MB0007 - 32.4% (56/173)

  19. 계속하여 vancomycin 억제대를 작게 보고한 기관 S. aureus: 28 기관(미흡 51기관 중 54.9%) E. faecalis: 36 기관(미흡 56기관 중 64.3%) Both: 27 기관(총 173기관 중 15.6%)

  20. Vancomycin (30g) 기준 R I S • Staphylococcus spp. 15 (mm) • 14mm이하: MIC를 측정한다. • Enterococcus spp. 14 15-16 17 (mm) NCCLS M100-S10, 2000

  21. Oxacillin (1g) 기준 R I S • S. aureus10 11-12 13 (mm) • Coagulase-negative staphylococci 17 18 (mm) NCCLS M100-S10, 2000

  22. Ampicillin (10g) 기준 R S • Enterobacteriaceae 13 17 (mm) • Staphylococci 28 29 • Enterococci 16 17 NCCLS M100-S10, 2000

  23. MB0010 Klebsiella pneumoniae ATCC700603 Positive control strain for extended-spectrum -lactamase Cefotaxime disk 27mm Ceftazidime disk 22mm Aztreonam disk 27mm Cefpodoxime disk 22mm

  24. ESBL-producing E. coli & Klebsiella Criteria Susceptible ESBL test • Cefotaxime  23 27 mm • Ceftazidime  18  22 • Aztreonam  22  27 • Cefpodoxime  21  22 • Ceftriaxone  21  25 NCCLS M2-A7, 2000

  25. Double disk synergy test; ESBL Cefotaxime Amoxicillin/Clavulanic acid Ceftazidime Aztreonam

  26. Salmonella spp.

  27. Shigella sonnei

  28. Effective -lactams for ESBL • Carbapenems • Imipenem, meropenem • Cephamycins • Cefotetan, cefoxitin, cefmetazole • Anti-Pseudomonas (4세대) cephalosporins • Cefepime, cefpirome • -lactamase inhibitor • Piperacillin/tazobactam

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