지역사회 획득 급성 신우신염의 원인균 및 ciprofloxacin 저항성에 대한 연구 = Causative Organisms and Antibiotics Sensitivity in Community Acquired Acute Pyelonephritis

다국어 초록 (Multilingual Abstract)

Purpose : Ciprofloxacin has been used as one of choice antibiotics for the empirical treatment of community-acquired acute pyelonephritis (APN), of which E-coli is the main causative bacterium. Recently, however, some studies show that ciprofloxacin-resistant E.coli is increasing in APN. In this study, authors aimed to re-evaluate ciprofloxacin as one of initial antibiotics for APN according to the survey of the patients' clinical and microbiologic characteristics.
Method : In this single center, the records of patients diagnosed as APN were reviewed retrospectively who visited emergency room or out-patient clinic from Aug. 01, 2005 to Jul. 31, 2007.
Result : A total of 303 patients were enrolled. The proportion of males to females was 1:9.4, the average age was 49.3±19 years old. Complicated APNs were 121 out of 303 patients, diabetes ranked highest, 52.5% (64/121). According to the urine culture analysis, the patients with isolated microorganism reached up to 45.2% (137/303) and E.coli occupied 94.2% out of total. As the initial antibiotics, ciprofloxacin was most commonly used (64.4%, 195/303), next was the 3rd generation cephalosporin (23.8%, 72/303). The analysis of antibiotics sensitivity demonstrated ciprofloxacin susceptibility was 81.4%, whereas high over 90% in the 3rd generation cephalosporin. When the ciprofloxacin-resistant E.coli was isolated, the patients tended to have prolonged duration of antibiotics treatment, a higher proportion of complicated APNs and of treatment non-responders.
Conclusion : For the APNs, ciprofloxacin is clinically effective initial antibiotics; however, it should be carefully used especially in case of the patients having combined underlying disease or the aged.

국문 초록 (Abstract)

목 적 : 급성 신우신염의 경험적 치료로 fluoroquinolone 제제를 사용하고 있으나 E. coli의 ciprofloxacin에 대한 내성균이 증가하고 있는 것으로 알려져 있다. 본 연구에서는 지역사회에서 발병한 급성 신우신염 환자의 임상적 특징 및 미생물학적 특성을 조사하여 초기 경험적 항생제의 선택에 대하여 재고하고자 한다.
방 법 : 2005년 8월 1일부터 2007년 7월 31일까지 서울대학교 보라매병원의 응급실 혹은 외래에서 급성 신우신염으로 진단받은 환자의 의무기록을 후향적으로 검토하였고, 병원 내에서 감염된 경우는 제외하였다.
결 과 : 총 303명이 연구 대상에 포함되었다. 남녀 비는 1: 9.4였고, 평균 연령은 49.3±19세 (평균±표준편차)였다. 복합성 급성 신우신염은 39.9% (121/303)였다. 요 배양 검사 결과를 분석한 결과 균이 동정된 경우는 전체의 45.2% (137/303) 이었는데, 그 중 E.coli가 94.2%로 가장 많았다. E.coli의 항생제 감수성을 조사한 결과 ciprofloxacin의 감수성은 81.4%였으나 3세대 cephalosporin의 경우 거의 90 % 이상의 높은 감수성을 보였다. ciprofloxacin 저항성 E.coli가 동정된 경우는 ciprofloxacin 감수성 군에 비해 항생제 사용 기간이 길었으며 (p=0.002), 복합성 급성 신우신염인 경우가 많았고 (p=0.002), 초기 치료에 반응을 보이지 않는 경우 (p=0.028)가 통계적으로 유의하게 많았다. 초기 치료에 반응을 보이지 않은 약 13% (40/303) 가운데 28명이 초기 항생제로 ciprofloxacin을 사용하였다. 그러나 ciprofloxacin 저항성 E.coli가 자란 경우에도 ciprofloxacin을 초기 항생제로 사용한 경우 약 50% (7/15)에서 임상적인 호전을 보였다.
결 론 : 지역사회 획득 급성 신우신염에서 초기 항생제로 ciprofloxacin을 사용하는 것은 임상적인 효과는 아직까지 유효하나 기저 질환이 있는 경우나 고령의 환자인 경우, ciprofloxacin 저항균이 원인일 가능성이 높으므로 ciprofloxacin 사용에 신중을 기해야 할 것이다.

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