Frequency Of blaCTX-M, blaTEM and blaSHV Genes in

Citrobacters Isolated from Imam Reza Hospital in Kermanshah

1
Alisha Akya ,
2
Somayeh Jafari ,
3
Kamal Ahmadi ,
3
Azam Elahi
1
Associate Professor, Department of Medical Microbiology, Nosocomial Infection Research Center, Kermanshah University of
Medical Sciences, Kermanshah, Iran
2
MSc in Medical Microbiology, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
3
MSc in Medical Microbiology, Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran

(Received June 16, 2015 ; Accepted July 12, 2015)

Abstract

Background and purpose: Citrobacter species can cause opportunistic hospital-acquired

infections and their treatment has become problematic following the acquisition of extended spectrum
beta- lactamases (ESBLs). The purpose of this study was to determine the frequency of ESBL genes in
clinical isolates in Kermanshah Imam Reza Hospital.
Materials and methods: In this study, 70 Citrobacter isolates were collected from various
clinical specimens and confirmed by standard bacteriological tests and API20E Kit. After antibiotic
susceptibility testing using disk diffusion method, the presence of ESBL phenotype was determined by
combined disk test. Specific primers were used to detect blaCTX-M, blaTEM and blaSHV genes among
isolates using PCR. Data was analyzed in SPSS V.18 applying Chi-Square test and Fisher's exact test.
Results: From 70 isolates of Citrobacter, 5 (7.1%) were phenotypically positive for ESBL. The
PCR test determined 19 isolates (31.6%) genetically positive for ESBL, and the frequency of blaCTX-M,
blaTEM and blaSHV genes were 21.3%, 11.4% and 1.4%, respectively. The highest antibiotic resistance
of isolates was to cefazolin (84.8%), ampicillin (71.2%) and co-trimoxazole (36.4%), and the lowest was
to gentamicin (9.1%), piperacillin/tazobactam (4.5%), and imipenem (1.5%).
Conclusion: The results showed that Citrobacter freundiii was the dominant species for
hospital-acquired infections in Kermanshah. A high percentage of isolates contained ESBL genes and
blaCTX-M was the most common. There was a high gap between the frequencies of genotypic and
phenotypic for ESBL, which may indicate ESB genes are not highly expressed in Citrobacter isolates.

Keywords: blaCTX-M, blaSHV, blaTEM, Citrobacter Spp

J Mazandaran Univ Med Sci 2015; 25(127): 65-73 (Persian).

65
 ‫ﭘﮋوﻫﺸﻲ‬

‫ﻣﺠـــﻠـــــﻪ داﻧـﺸــــﮕﺎه ﻋـــﻠــــﻮم ﭘــﺰﺷــﻜــــﻲ ﻣــﺎزﻧـــــﺪران‬

‫دوره ﺑﻴﺴﺖ و ﭘﻨﺠﻢ ﺷﻤﺎره ‪ 127‬ﻣﺮداد ﺳﺎل ‪(65-73) 1394‬‬

‫ﻓﺮاواﻧﻲ ژن ﻫﺎي ‪ blaTEM ،blaCTX-M‬و ‪ blaSHV‬در اﻳﺰوﻟﻪ ﻫﺎي‬

‫ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﺟﺪاﺷﺪه از ﺑﻴﻤﺎرﺳﺘﺎن اﻣﺎم رﺿﺎ )ع( در ﻛﺮﻣﺎﻧﺸﺎه‬
‫‪1‬‬
‫ﻋﻠﻴﺸﺎ اﻛﻴﺎ‬
‫‪2‬‬
‫ﺳﻤﻴﻪ ﺟﻌﻔﺮي‬
‫‪3‬‬
‫ﻛﻤﺎل اﺣﻤﺪي‬
‫‪3‬‬
‫اﻋﻈﻢ اﻟﻬﻲ‬

‫ﭼﻜﻴﺪه‬
‫ﺳﺎﺑﻘﻪ و ﻫـﺪف‪ :‬ﮔﻮﻧـﻪﻫـﺎي ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ ﻋﻔﻮﻧـﺖﻫـﺎي ﻓﺮﺻـﺖ ﻃﻠـﺐ ﺑﻴﻤﺎرﺳـﺘﺎﻧﻲ اﻳﺠـﺎد ﻣـﻲﻛﻨﻨـﺪ و ﺑـﻪ دﻧﺒـﺎل ﻛﺴـﺐ‬
‫ﺑﺘﺎﻻﻛﺘﺎﻣﺎزﻫﺎي داﻣﻨﻪ ﮔﺴﺘﺮده )‪ (ESBL‬درﻣﺎن آن ﻫﺎ ﻣﺸﻜﻞ ﺳﺎز ﺷﺪه اﺳﺖ‪ .‬ﻫﺪف از اﻳـﻦ ﻣﻄﺎﻟﻌـﻪ ﺑﺮرﺳـﻲ ﻓﺮاواﻧـﻲ ژن ﻫـﺎي‬
‫‪ ESBL‬در اﻳﺰوﻟﻪﻫﺎي ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ در ﺑﺰرگ ﺗﺮﻳﻦ ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻬﺮ ﻛﺮﻣﺎﻧﺸﺎه )اﻣﺎم رﺿﺎ( در ﺳﺎل ‪ 1393-1392‬ﺑﻮد‪.‬‬
‫ﻣﻮاد و روشﻫﺎ‪ :‬ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ از ﻧﻮع ﺗﻮﺻﻴﻔﻲ‪ -‬ﺗﺤﻠﻴﻠﻲ ﺑﻮد‪ .‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ‪ 70‬ﺟﺪاﻳﻪ ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ از ﻧﻤﻮﻧﻪﻫﺎي ﺑﺎﻟﻴﻨﻲ‬
‫ﺟﻤﻊآوري ﺷﺪ و ﺑﻪ وﺳﻴﻠﻪ ﺗﺴﺖﻫﺎي اﺳﺘﺎﻧﺪارد ﺑﺎﻛﺘﺮيﺷﻨﺎﺳﻲ و ﻛﻴﺖ ‪ API 20E‬ﺗﺎﻳﻴﺪ ﺷﺪﻧﺪ‪ .‬ﭘﺲ از ﺳﻨﺠﺶ ﺣﺴﺎﺳﻴﺖ‬
‫آﻧﺘﻲﺑﻴﻮﺗﻴﻜﻲ ﺑﻪ روش اﻧﺘﺸﺎر دﻳﺴﻚ‪ ،‬وﺟﻮد آﻧﺰﻳﻢﻫﺎي ‪ ESBL‬از ﻧﻈﺮ ﻓﻨﻮﺗﻴﭙﻲ ﺑﻪ روش آزﻣﺎﻳﺶ دﻳﺴﻚ ﺗﺮﻛﻴﺒﻲ ﻣﺸﺨﺺ ﺷﺪ‪.‬‬
‫از ﭘﺮاﻳﻤﺮﻫﺎي اﺧﺘﺼﺎﺻﻲ ﺟﻬﺖ ﺗﻌﻴﻴﻦ ژنﻫﺎي ‪ blaTEM ،blaCTX-M‬و ‪ blaSHV‬در ﻣﻴﺎن ﺟﺪاﻳﻪﻫﺎ در آزﻣﺎﻳﺶ ‪ PCR‬اﺳﺘﻔﺎده‬
‫ﺷﺪ‪ .‬دادهﻫﺎ ﺗﻮﺳﻂ ﻧﺮماﻓﺰار ‪ SPSS‬ﻧﺴﺨﻪ ‪ 18‬و آزﻣﻮن ﻓﻴﺸﺮ و ﻛﺎي اﺳﻜﻮﻳﺮ )‪ (Chi-Square‬ﻣﻮرد ﺗﺠﺰﻳﻪ و ﺗﺤﻠﻴﻞ ﻗﺮار ﮔﺮﻓﺖ‪.‬‬
‫ﻳﺎﻓﺘﻪﻫﺎ‪ :‬از ‪ 70‬ﺟﺪاﻳﻪ ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ‪ 7/1) 5 ،‬درﺻﺪ( ﺟﺪاﻳﻪ از ﻧﻈﺮ ﻓﻨﻮﺗﻴﭙﻲ ﺑﺮاي ﺗﻮﻟﻴﺪ آﻧﺰﻳﻢﻫﺎي ﺑﺘﺎﻻﻛﺘﺎﻣﺎز داﻣﻨﻪ ﮔﺴـﺘﺮده‬
‫ﻣﺜﺒﺖ ﺷـﺪﻧﺪ‪ .‬آزﻣـﺎﻳﺶ ‪ PCR‬ﻧﺸـﺎن داد از ﻧﻈـﺮ ژﻧـﻮﺗﻴﭙﻲ ‪ 19‬اﻳﺰوﻟـﻪ )‪ 31/6‬درﺻـﺪ( ‪ ESBL‬ﻣﺜﺒـﺖ ﺷـﺪﻧﺪ و ﻓﺮاواﻧـﻲ ژنﻫـﺎي‬
‫‪ blaTEM ،blaCTX-M‬و ‪ blaSHV‬ﺑﻪ ﺗﺮﺗﻴﺐ ‪ 21/3‬درﺻﺪ‪ 11/4 ،‬درﺻﺪ و ‪ 1/4‬درﺻﺪ ﺑﻮد‪ .‬ﺑﻴﺶﺗﺮﻳﻦ ﻣﻘﺎوﻣﺖ آﻧﺘﻲﺑﻴﻮﺗﻴﻜﻲ ﺑﻪ‬
‫ﺳﻔﺎزوﻟﻴﻦ )‪ 84/8‬درﺻﺪ(‪ ،‬آﻣﭙﻲﺳـﻴﻠﻴﻦ )‪ 71/2‬درﺻـﺪ( و ﻛﻮﺗﺮﻳﻤﻮﻛﺴـﺎزول )‪ 36/4‬درﺻـﺪ( و ﻛـﻢﺗـﺮﻳﻦ ﻣﻘﺎوﻣـﺖ ﻧﺴـﺒﺖ ﺑـﻪ‬
‫ﺟﻨﺘﺎﻣﺎﻳﺴﻴﻦ )‪ 9/1‬درﺻﺪ(‪ ،‬ﭘﻴﭙﺮاﺳﻴﻠﻴﻦ‪/‬ﺗﺎزوﺑﺎﻛﺘﺎم )‪ 4/5‬درﺻﺪ( و اﻳﻤﻲﭘﻨﻢ )‪ 1/5‬درﺻﺪ( ﺑﻮد‪.‬‬
‫اﺳﺘﻨﺘﺎج‪ :‬ﻧﺘﺎﻳﺞ ﻧﺸﺎن داد ﻛﻪ ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﻓﺮوﻧﺪي ﮔﻮﻧﻪ ﻏﺎﻟﺐ در اﻳﺠﺎد ﻋﻔﻮﻧﺖﻫـﺎي ﺑﻴﻤﺎرﺳـﺘﺎﻧﻲ در ﻛﺮﻣﺎﻧﺸـﺎه ﻣـﻲﺑﺎﺷـﺪ‪.‬‬
‫ﻓﺮاواﻧﻲ ﻛﻠﻲ ﺟﺪاﻳﻪﻫﺎي ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ داراي ژنﻫﺎي ‪ ESBL‬ﺑﺎﻻ اﺳﺖ و در اﻳﻦ ﻣﻴﺎن ژن ‪ blaCTX-M‬داراي ﺑﻴﺶﺗـﺮﻳﻦ ﺷـﻴﻮع‬
‫ﻧﺴﺒﻲ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺑﻴﻦ ﻓﺮاواﻧﻲ ﻓﻨﻮﺗﻴﭙﻲ و ژﻧﻮﺗﻴﭙﻲ ‪ ESBL‬در اﻳﺰوﻟﻪﻫﺎي ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ اﺧﺘﻼف زﻳﺎدي وﺟﻮد داﺷﺖ ﻛﻪ ﻣﻤﻜﻦ اﺳﺖ‬
‫ﻧﺸﺎﻧﮕﺮ ﻋﺪم ﺑﻴﺎن ﺑﺎﻻي ژنﻫﺎي ‪ ESBL‬در اﻳﺰوﻟﻪ ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﺑﺎﺷﺪ‪.‬‬

‫واژه ﻫﺎي ﻛﻠﻴﺪي‪ ،blaSHV ،blaTEM ،blaCTX-M :‬ﮔﻮﻧﻪ ﻫﺎي ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ‬

‫ﻣﻘﺪﻣﻪ‬
‫ﮔﻮﻧﻪ ﻫﺎي ﻣﻬﻢ اﻳﻦ ﺑـﺎﻛﺘﺮي ﺷـﺎﻣﻞ ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ ﻓﺮوﻧـﺪي‬ ‫ﺳــﻴﺘﺮوﺑﺎﻛﺘﺮ )‪ (Citrobacter‬ﺑﺎﺳــﻴﻞ ﮔــﺮم ﻣﻨﻔــﻲ و‬
‫)‪ ،(Citrobacter freundiii‬ﺳﻴﺘﺮوﺑﺎﻛﺘﺮﻛﻮﺳﺮي)‪،(C.koseri‬‬ ‫ﺑﻲﻫﻮازي اﺧﺘﻴﺎري از ﺧﺎﻧﻮاده اﻧﺘﺮوﺑﺎﻛﺘﺮﻳﺎﺳﻪ ﻫـﺎ اﺳـﺖ و‬

‫‪E-mail: bartar2004@yahoo.com‬‬ ‫ﻣﻮﻟﻒ ﻣﺴﺌﻮل‪ :‬ﺳﻤﻴﻪ ﺟﻌﻔﺮي‪ -‬ﻛﺮﻣﺎﻧﺸﺎه‪ :‬ﺑﺎغ اﺑﺮﻳﺸﻢ‪ ،‬ﺑﻠﻮار ﭘﺮﺳﺘﺎر‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن اﻣﺎم رﺿﺎ )ع(‪ ،‬آزﻣﺎﻳﺸﮕﺎه‬
‫‪ .1‬داﻧﺸﻴﺎر‪ ،‬ﮔﺮوه ﻣﻴﻜﺮوب ﺷﻨﺎﺳﻲ ﭘﺰﺷﻜﻲ‪ ،‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﻋﻔﻮﻧﺖ ﻫﺎي ﺑﻴﻤﺎرﺳﺘﺎﻧﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻛﺮﻣﺎﻧﺸﺎه‪ ،‬ﻛﺮﻣﺎﻧﺸﺎه‪ ،‬اﻳﺮان‬
‫‪ .2‬ﻛﺎرﺷﻨﺎس ارﺷﺪ ﻣﻴﻜﺮوب ﺷﻨﺎﺳﻲ‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن اﻣﺎم رﺿﺎ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻛﺮﻣﺎﻧﺸﺎه‪،‬ﻛﺮﻣﺎﻧﺸﺎه‪ ،‬اﻳﺮان‬
‫‪ .3‬ﻛﺎرﺷﻨﺎس ارﺷﺪ ﻣﻴﻜﺮوب ﺷﻨﺎﺳﻲ‪ ،‬ﻛﻤﻴﺘﻪ ﺗﺤﻘﻴﻘﺎت داﻧﺸﺠﻮﻳﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻛﺮﻣﺎﻧﺸﺎه‪ ،‬ﻛﺮﻣﺎﻧﺸﺎه‪ ،‬اﻳﺮان‬
‫ﺗﺎرﻳﺦ ﺗﺼﻮﻳﺐ ‪1394/4/21 :‬‬ ‫ﺗﺎرﻳﺦ ارﺟﺎع ﺟﻬﺖ اﺻﻼﺣﺎت ‪1394/3/18:‬‬ ‫‪ ‬ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ‪1394/3/16:‬‬

‫دوره ﺑﻴﺴﺖ و ﭘﻨﺠﻢ‪ ،‬ﺷﻤﺎره ‪ ، 127‬ﻣﺮداد ‪1394‬‬ ‫ﻣﺠﻠﻪ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻣﺎزﻧﺪران‬ ‫‪66‬‬
‫ﻋﻠﻴﺸﺎ اﻛﻴﺎ و ﻫﻤﻜﺎران‬
‫اﻳﻦ ﻣﻄﺎﻟﻌـﻪ ﺑﺮرﺳـﻲ ﻓﺮاواﻧـﻲ ‪ 3‬ﻧـﻮع ﺷـﺎﻳﻊ ‪ ESBL‬ﻳﻌﻨـﻲ‬
‫‪ blaTEM ،blaCTX-M‬و ‪ blaSHV‬و ﻣﻘﺎوﻣــــــــــــﺖ‬
‫آﻧﺘـــﻲﺑﻴـــﻮﺗﻴﻜﻲ اﻳﺰوﻟـــﻪﻫـــﺎي ﺳـــﻴﺘﺮوﺑﺎﻛﺘﺮ ﺟﺪاﺷـــﺪه از‬
‫ﻧﻤﻮﻧﻪﻫﺎي ﺑﺎﻟﻴﻨﻲ ﺑﻮد‪.‬‬
‫وﺟﻮد دارﻧﺪ)‪ .(1‬ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ از ﺟﻤﻠﻪ ﭘﺎﺗﻮژنﻫﺎي ﻓﺮﺻـﺖ‬
‫ﻣﻮاد و روش ﻫﺎ‬
‫ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ از ﻧﻮع ﺗﻮﺻﻴﻔﻲ ﺗﺤﻠﻴﻠـﻲ ﺑـﻮد‪ .‬در اﻳـﻦ‬
‫ﺗﺤﻘﻴﻖ ﺗﻌﺪاد ‪ 70‬ﺟﺪاﻳﻪ ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ از ‪ 180‬ﻧﻤﻮﻧـﻪ ﺑـﺎﻟﻴﻨﻲ‬
‫ﻣﺨﺘﻠﻒ )ادرار‪ ،‬ﻣﺪﻓﻮع‪ ،‬ﺧﻠﻂ‪ ،‬زﺧﻢ و ﺧـﻮن( از ﺑﻴﻤـﺎران‬
‫ﺑﺰرگﺗﺮﻳﻦ ﺑﻴﻤﺎرﺳﺘﺎن در ﺷﻬﺮ ﻛﺮﻣﺎﻧﺸـﺎه )اﻣـﺎم رﺿـﺎ( در‬
‫ﺳﺎل ‪ 1392-1393‬ﺟﺪا ﺷﺪ و ﻣﻮرد ﺑﺮرﺳﻲ ﻗـﺮار ﮔﺮﻓـﺖ‪.‬‬
‫ﻧﻤﻮﻧــﻪﻫــﺎي ﻣــﺬﻛﻮر ﭘــﺲ از ﺟﻤــﻊآوري اوﻟﻴــﻪ در ﻛﻨــﺎر‬
‫ﺑﺎﻛﺲ ﻳﺦ و رﻋﺎﻳﺖ ﺷﺮاﻳﻂ اﺳﺘﺮﻳﻞ ﺑﻪ آزﻣﺎﻳﺸـﮕﺎه اﻧﺘﻘـﺎل‬
‫داده ﺷﺪ‪ .‬ﭘﺲ از ﺟﺪاﺳﺎزي اوﻟﻴﻪ ﺑﺎ اﺳـﺘﻔﺎده از روشﻫـﺎي‬
‫ﻣﻴﻜﺮوبﺷﻨﺎﺳﻲ و ﺑﻴﻮﺷﻴﻤﻴﺎﻳﻲ‪ ،‬ﺑﺎﻛﺘﺮيﻫﺎ ﺟﺪا ﺷﺪﻧﺪ و ﺟﻬﺖ‬
‫ﺗﺄﻳﻴﺪ ﻧﻬﺎﻳﻲﮔﻮﻧﻪﻫﺎ ازﻛﻴﺖ ‪) API-20E‬ﻓﺮاﻧﺴﻪ ‪(BioMérieux‬‬
‫اﺳﺘﻔﺎده ﺷﺪ‪ .‬ﺳﭙﺲ ﺑﻪﻣﻨﻈﻮر ﺷﻨﺎﺳﺎﻳﻲ ﻣﻘﺎوﻣﺖ آﻧﺘﻲﺑﻴـﻮﺗﻴﻜﻲ‬
‫ﺑﺎﻛﺘﺮيﻫﺎ از روش اﻧﺘﺸﺎر دﻳﺴﻚ ﺑﺎ ﺳﻮش ﻛﻨﺘﺮل اﺳـﺘﺎﻧﺪارد‬
‫)‪ (E.coli ATCC 25922‬اﺳﺘﻔﺎده ﺷﺪ‪ .‬از اﻳﺰوﻟﻪﻫﺎي ﻣـﻮرد‬
‫ﺑﺮرﺳﻲ ﺳﻮﺳﭙﺎﻧﺴﻴﻮﻧﻲ ﺑﺮاﺑﺮ ﻏﻠﻈﺖ ﻧﻴﻢ ﻣﻚ ﻓﺎرﻟﻨﺪ ﺗﻬﻴﻪ ﺷـﺪ‪.‬‬
‫ﭘﺲ از ﻛﺸﺖ ﺑـﺮ روي ﻣﺤـﻴﻂ ﻣـﻮﻟﺮ ﻫﻴﻨﺘـﻮن آﮔـﺎر )ﻣـﺮك‬
‫آﻟﻤﺎن(‪ ،‬دﻳﺴﻚﻫﺎي آﻧﺘﻲﺑﻴﻮﺗﻴﻚ ﺑﺎ ﻓﺎﺻﻠﻪ ‪ 2/5‬ﺳﺎﻧﺘﻲﻣﺘـﺮي‬
‫از ﻫﻢ روي ﭘﻠﻴﺖ ﻗﺮار داده ﺷﺪﻧﺪ و ﺳﭙﺲ ﺑـﻪ ﻣـﺪت ‪18-24‬‬
‫ﺳﺎﻋﺖ در دﻣﺎي ‪ 35-37‬درﺟﻪ ﺳﺎﻧﺘﻴﮕﺮاد اﻧﻜﻮﺑـﻪ ﮔﺮدﻳﺪﻧـﺪ‪.‬‬
‫ﻧﺘﺎﻳﺞ ﺣﺎﺻﻞ ﺑﺎ ﻣﻌﻴﺎرﻫﺎي ‪ CLSI‬ﺳﺎل ‪ 2013‬ﻣﻘﺎﻳﺴﻪ ﺷﺪ)‪.(14‬‬
‫ﺟﺪاﻳﻪﻫﺎﻳﻲ ﻛﻪ ﻗﻄﺮ ﻫﺎﻟﻪ ﻋﺪم رﺷﺪ آنﻫﺎ ﺣﺪاﻗﻞ ﺑﺮاي ﻳﻜـﻲ‬
‫از آﻧﺘﻲﺑﻴﻮﺗﻴﻚﻫﺎي ﺳﻔﺘﺎزﻳﺪﻳﻢ‪ ،‬ﺳﻔﻮﺗﺎﻛﺴﻴﻢ‪ ،‬ﺳﻔﺘﺮﻳﺎﻛﺴـﻮن‬
‫و آزﺗﺮوﻧﺎم ﺑﻪﺗﺮﺗﻴﺐ ‪ 25 ،27 ،22‬و‪ 27‬ﻣﻴﻠﻲﻣﺘﺮ و ﻳﺎ ﻛﻢﺗـﺮ‬
‫ﺑﻮد‪ ،‬ﻃﺒﻖ ﭘﻴﺸـﻨﻬﺎد ‪ CLSI‬از ﻧﻈـﺮ داﺷـﺘﻦ ‪ ESBL‬ﺑﺮرﺳـﻲ‬
‫ﺷﺪﻧﺪ)‪ .(14‬ﺳﭙﺲ ﺑﺮاي ﻏﺮﺑﺎﻟﮕﺮي ﻓﻨﻮﺗﻴﭙﻲ اﻳﺰوﻟﻪﻫـﺎ ﻣﻮﻟـﺪ‬
‫‪ ،ESBL‬از روش دﻳﺴﻚ ﺗﺮﻛﻴﺒﻲ اﺳﺘﻔﺎده ﺷﺪ‪ .‬در اﻳﻦ روش‬
‫از دﻳﺴﻚﻫﺎي ‪ 30‬ﻣﻴﻜﺮوﮔﺮﻣﻲ ﺳﻔﻮﺗﺎﻛﺴﻴﻢ و ﺳﻔﺘﺎزﻳﺪﻳﻢ‬
‫در ﻣﺠﺎورت دﻳﺴﻚ ﻣﺮﻛﺐ آنﻫﺎ‪ ،‬ﺣﺎوي ‪ 10‬ﻣﻴﻜﺮوﮔﺮم‬
‫ﻛﻼوﻻﻧﻴﻚ اﺳﻴﺪ )اﻧﮕﻠﺴـﺘﺎن ‪ ،(MAST,‬در ﻣﺤـﻴﻂ ﻣـﻮﻟﺮ‬
‫‪67‬‬ ‫دوره ﺑﻴﺴﺖ و ﭘﻨﺠﻢ‪ ،‬ﺷﻤﺎره ‪ ، 127‬ﻣﺮداد ‪1394‬‬
‫ﭘﮋوﻫﺸﻲ‬
‫ﺳــــــــﻴﺘﺮوﺑﺎﻛﺘﺮ اﻣــــــــﺎﻻﻧﺘﻴﮕﻮس )‪،(C.amalantigus‬‬
‫ﺳــﻴﺘﺮوﺑﺎﻛﺘﺮ ﺑﺮاﻛﻴـﻲ )‪ (C.braakii‬و ﺳــﻴﺘﺮوﺑﺎﻛﺘﺮ ﻳــﺎﻧﮕﺌﻲ‬
‫)‪ (C.youngae‬ﻫﺴﺘﻨﺪ‪ .‬اﻳﻦ ﺑـﺎﻛﺘﺮيﻫـﺎ ﺑـﻴﺶﺗـﺮ در ﻣﻨـﺎﺑﻊ‬
‫آب‪ ،‬ﺧﺎك‪ ،‬ﻏﺬا و ﻣﺠﺎري ﮔﻮارﺷﻲ ﺣﻴﻮاﻧﺎت و اﻧﺴﺎنﻫـﺎ‬
‫ﻃﻠﺒﻲ اﺳﺖ ﻛﻪ ﻣﻲﺗﻮاﻧﺪ ﺑﺎﻋﺚ ﺑﻴﻤﺎريﻫﺎي ﻣﺨﺘﻠﻔﻲ از ﺟﻤﻠـﻪ‬
‫اﺳﻬﺎل‪ ،‬ﺳﭙﺘﻲ ﺳﻤﻲ‪ ،‬ﻣﻨﻨﮋﻳﺖ و ﻋﻔﻮﻧﺖ ﻣﺠـﺎري ادراري و‬
‫ﺗﻨﻔﺴﻲ ﺑﻪ ﺧﺼﻮص در ﮔﺮوهﻫﺎي ﭘﺮﺧﻄﺮ ﻣﺜـﻞ ﻧـﻮزادان و‬
‫اﻓﺮاد داراي ﻧﻘﺺ ﺳﻴﺴﺘﻢ اﻳﻤﻨﻲ ﺷﻮد)‪ .(2‬ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﺑﻪ ﻋﻨﻮان‬
‫ﻳﻚ ﭘﺎﺗﻮژن ﺑﻴﻤﺎرﺳﺘﺎﻧﻲ ﺑﺎ ﻣﻘﺎوﻣﺖ ﭼﻨﺪ داروﻳﻲ و ﺑـﺎ ﺷـﻴﻮع‬
‫در ﺣﺎل اﻓـﺰاﻳﺶ در ﺟﻬـﺎن ﺷـﻨﺎﺧﺘﻪ ﺷـﺪه اﺳـﺖ)‪ .(3‬اﻳـﻦ‬
‫ﺑﺎﻛﺘﺮي ﺑﻪ دﻟﻴﻞ ﺑﺎﻻ ﺑﻮدن ﻧﺮخ ﻣﺮگ و ﻣﻴﺮ ﻋﻔﻮﻧﺖﻫـﺎي آن‬
‫)‪ 30-60‬درﺻﺪ( و ﻫﻢﭼﻨﻴﻦ ﺗﻮاﻧﺎﻳﻲ اﻳﺠـﺎد ﻋﻔﻮﻧـﺖﻫـﺎي‬
‫ﺗﻬﺪﻳﺪﻛﻨﻨﺪه ﺣﻴﺎت در اﻓـﺮاد ﺑﺴـﺘﺮي در ﺑﻴﻤﺎرﺳـﺘﺎن ﻫـﺎ و‬
‫ﻣﻘﺎوﻣﺖ ﺑﺎﻻي داروﻳﻲ داراي اﻫﻤﻴﺖ اﺳﺖ)‪.(3-5‬‬
‫ﺑﺘﺎﻻﻛﺘﺎﻣﺎزﻫﺎي داﻣﻨﻪ ﮔﺴﺘﺮده )‪ (ESBL‬از ﺟﻤﻠﻪ ﻋﻮاﻣﻞ‬
‫اﻧﺘﺸﺎر وﺳﻴﻊ ﻣﻘﺎوﻣﺖﻫﺎي آﻧﺘﻲﺑﻴﻮﺗﻴﻜﻲ در ﺑﺎﻛﺘﺮيﻫﺎ ﺑﻮده‬
‫و اﻧﺘﻘﺎل آنﻫﺎ ﺑﻪ ﻃﻮر ﭘﻴﻮﺳﺘﻪ در ﻣﻴﺎن اﻧﺘﺮوﺑﺎﻛﺘﺮﻳﺎﺳﻪﻫـﺎ از‬
‫ﺟﻤﻠﻪ ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﺻﻮرت ﻣـﻲﮔﻴـﺮد)‪ .(6-8‬اﻳـﻦ آﻧـﺰﻳﻢﻫـﺎ‬
‫داراي ﭼﻬﺎر ﮔﺮوه از ‪ A‬ﺗﺎ ‪ D‬ﺑـﻮده و داراي ﺗﻨـﻮع ﺑـﺎﻻﻳﻲ‬
‫ﻫﺴﺘﻨﺪ‪ ،‬و در ﻃﻲ زﻣﺎن و ﻧﻴﺰ از ﻣﻜﺎﻧﻲ ﺑﻪ ﻣﻜـﺎن دﻳﮕـﺮ ﺗﻨـﻮع‬
‫ﭘﻴﺪا ﻣﻲﻛﻨﻨﺪ)‪ .(7-10‬وﺟﻮد اﻳﻦ آﻧﺰﻳﻢﻫﺎ ﺑـﻪﻃـﻮر ﮔﺴـﺘﺮده‬
‫در اﻧﺘﺮوﺑﺎﻛﺘﺮﻳﺎﺳــﻪﻫــﺎي ﺟــﺪا ﺷــﺪه از ﺑﻴﻤــﺎران ﺑﺴــﺘﺮي و‬
‫ﻫﻢﭼﻨﻴﻦ ﺑﺮرﺳـﻲ آﻟـﻮدﮔﻲ در ﺑﺨـﺶﻫـﺎي ﺑﻴﻤﺎرﺳـﺘﺎنﻫـﺎ‬
‫ﮔــﺰارش ﺷــﺪه اﺳــﺖ)‪ .(11،10‬ﺑﻨــﺎﺑﺮاﻳﻦ اﻧﺠــﺎم آزﻣﺎﻳﺸــﺎت‬
‫ﻓﻨﻮﺗﻴﭙﻲ ‪ ESBL‬و اﺳﺘﻔﺎده از روشﻫﺎي ﻣﻠﻜﻮﻟﻲ اﻃﻼﻋﺎت‬
‫ﺑﻬﺘﺮي از اﻧﺘﺸﺎر ﻣﻘﺎوﻣﺖ آﻧﺘﻲ ﺑﻴﻮﺗﻴﻜﻲ در اﻳﻦ ﺑﺎﻛﺘﺮيﻫـﺎ‬
‫ﺑﻪ دﺳﺖ ﻣﻲدﻫﺪ)‪ .(13،12‬اﻧﺘﻈﺎر ﻣـﻲرود ﺷـﻴﻮع ‪ESBL‬ﻫـﺎ‬
‫در ﻣﻴــﺎن ﮔﻮﻧــﻪﻫــﺎي ﺳــﻴﺘﺮوﺑﺎﻛﺘﺮ ﺑــﻪ دﻟﻴــﻞ اﺳــﺘﻔﺎده از‬
‫آﻧﺘﻲﺑﻴﻮﺗﻴﻚﻫـﺎي ﻃﻴـﻒ ﮔﺴـﺘﺮده در ﻣﺮاﻛـﺰ درﻣـﺎﻧﻲ در‬
‫ﺣــﺎل اﻓــﺰاﻳﺶ ﺑﺎﺷــﺪ‪ .‬از ﻃﺮﻓــﻲ ﻣﻄﺎﻟﻌــﻪ روي ﮔﻮﻧــﻪﻫــﺎي‬
‫ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ در ﻣﻘﺎﻳﺴﻪ ﺑﺎ دﻳﮕﺮ ﺑـﺎﻛﺘﺮيﻫـﺎي ﺑﻴﻤـﺎريزاي‬
‫ﺧﺎﻧﻮاده اﻧﺘﺮوﺑﺎﻛﺘﺮﻳﺎﺳﻪ ﻛﻢﺗـﺮ ﺻـﻮرت ﮔﺮﻓﺘـﻪ اﺳـﺖ‪ .‬در‬
‫ﻧﺘﻴﺠﻪ اﻃﻼﻋﺎت ﻛﻤﻲ در اﻳـﻦ ﻣـﻮرد وﺟـﻮد دارد‪ .‬ﻫـﺪف‬
‫ﻣﺠﻠﻪ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻣﺎزﻧﺪران‬
‫ﻣﺸﺨﺼﺎت ﻧﻤﻮﻧﻪﻫﺎي ﻣﻮرد ﺑﺮرﺳﻲ در ﻳـﻚ ﻓﺎﻳـﻞ اﻛﺴـﻞ‬ ‫ﻫﻴﻨﺘﻮن آﮔﺎر اﺳﺘﻔﺎده ﺷﺪ و آزﻣـﺎﻳﺶ ﻣﺎﻧﻨـﺪ روش اﻧﺘﺸـﺎر‬
‫)‪ (Excel‬ﺟﻤﻊ آوري ﮔﺮدﻳﺪ و ﺑﺎ ﻧﺮم اﻓـﺰار ‪ SPSS‬ﻧﺴـﺨﻪي‬ ‫دﻳﺴﻚ اﻧﺠﺎم ﮔﺮﻓﺖ‪ .‬در ﺻﻮرﺗﻲﻛﻪ ﻗﻄﺮ ﻫﺎﻟﻪ ﻋﺪم رﺷـﺪ‬
‫‪ 18‬ارﺗﺒﺎط ﻣﺘﻐﻴﺮﻫﺎ ﺑﺎ اﺳﺘﻔﺎده از آزﻣﻮن ﻓﻴﺸﺮ و ﻛﺎي اﺳـﻜﻮﻳﺮ‬ ‫ﺑﺎﻛﺘﺮي اﻃﺮاف دﻳﺴﻚ ﺗﺮﻛﻴﺒﻲ ﺣـﺪاﻗﻞ ‪ 5‬ﻣﻴﻠـﻲﻣﺘـﺮ و ﻳـﺎ‬
‫)‪ (Chi-Square‬ﻣﻮرد ﺗﺠﺰﻳﻪ و ﺗﺤﻠﻴﻞ ﻗﺮار ﮔﺮﻓﺖ‪.‬‬ ‫ﺑﻴﺶﺗﺮ از ﻗﻄﺮ ﻫﺎﻟﻪ ﻋﺪم رﺷﺪ اﻃﺮاف دﻳﺴﻚ ﻣﻨﻔﺮد ﻫﻤﺎن‬
‫آﻧﺘﻲﺑﻴﻮﺗﻴﻚ ﺑﻮد‪ ،‬ﺑﻪ ﻋﻨـﻮان ﺳـﻮﻳﻪ ﻣﻮﻟـﺪ ﺑﺘﺎﻻﻛﺘﺎﻣﺎزﻫـﺎي‬

‫ﻳﺎﻓﺘﻪ ﻫﺎ‬ ‫داﻣﻨﻪ ﮔﺴﺘﺮده ﻗﻠﻤﺪاد ﮔﺮدﻳـﺪ)‪ .(14‬در ﻣﺮﺣﻠـﻪ ﺑﻌـﺪ ﺟﻬـﺖ‬
‫ﺑﺮرﺳﻲ ﻓﺮاواﻧﻲ ژنﻫﺎي ‪ blaTEM ،blaCTX-M‬و ‪blaSHV‬‬
‫از‪ 70‬ﻧﻤﻮﻧﻪ ﻣﻮرد ﺑﺮرﺳﻲ‪ 42 ،‬ﻧﻤﻮﻧﻪ از ﺑﻴﻤﺎران ﺧـﺎﻧﻢ‬
‫ﺑﻪ ﻛﻤﻚ ﭘﺮاﻳﻤﺮﻫـﺎي اﺧﺘﺼﺎﺻـﻲ ﻃﺒـﻖ ﺟـﺪول ﺷـﻤﺎره ‪،1‬‬
‫و ‪ 28‬ﻧﻤﻮﻧــﻪ ﻣﺮﺑــﻮط ﺑــﻪ آﻗﺎﻳــﺎن ﺑــﻮد‪ .‬ﻣﻴــﺎﻧﮕﻴﻦ ﺳــﻨﻲ ﻛــﻞ‬
‫واﻛﻨﺶ ‪ PCR‬اﻧﺠﺎم ﺷﺪ)‪ .(15-17‬اﺑﺘﺪا ﻛﻞ ﻣﺤﺘﻮاي ژﻧﻮﻣﻲ‬
‫ﺑﻴﻤــﺎران ‪ 39/8 ± 29/7‬ﺳــﺎل ﺑــﻮد‪ .‬ﺑــﻴﺶﺗــﺮﻳﻦ ﻓﺮاواﻧــﻲ‬
‫ﺑﺎﻛﺘﺮي ﺑﺎ روش ‪ Boiling‬اﺳـﺘﺨﺮاج ﺷـﺪ‪ .‬ﺑـﻪ اﻳـﻦ ﻣﻨﻈـﻮر‬
‫ﺟﺪاﻳﻪﻫـﺎ ﻣﺮﺑـﻮط ﺑـﻪ ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ ﻓﺮوﻧـﺪي ﺑـﺎ ‪ 60‬اﻳﺰوﻟـﻪ‬
‫ﭼﻨــﺪﻳﻦ ﻛﻠﻨــﻲ ﺧــﺎﻟﺺ ﺑــﺎﻛﺘﺮي در ‪ 0/5 ml‬آب ﻣﻘﻄــﺮ‬
‫)‪ 85/7‬درﺻﺪ( ﺑﻮد‪ .‬ﺑﻴﺶ ﺗﺮﻳﻦ ﻓﺮاواﻧﻲ ﻧﻤﻮﻧـﻪ ﻫـﺎ در اﻳـﻦ‬
‫اﺳﺘﺮﻳﻞ ﺣﻞ ﺷـﺪ و ﭘـﺲ از ‪ 5‬دﻗﻴﻘـﻪ ﺟﻮﺷـﺎﻧﺪن و ﺧﻨـﻚ‬
‫ﭘﮋوﻫﺶ ﻣﺮﺑﻮط ﺑﻪ ﻧﻤﻮﻧﻪ ادرار ﺑﺎ ‪ 55/7) 39‬درﺻﺪ( ﻧﻤﻮﻧﻪ‬
‫ﺷﺪن در ﻣﺮﺣﻠﻪ ﺑﻌﺪ‪ ،‬در دور ‪ 7000×g‬ﺑـﻪ ﻣـﺪت ‪ 1‬دﻗﻴﻘـﻪ‬
‫ﺑﻮد و ﺳﭙﺲ ﺑﻪ ﺗﺮﺗﻴﺐ ﻣﺪﻓﻮع ﺑﺎ ‪ 22/9) 16‬درﺻﺪ(‪ ،‬ﺧﻠـﻂ‬
‫ﺳﺎﻧﺘﺮﻳﻔﻴﻮژ ﺷﺪ‪ .‬ﻣﺤﻠﻮل روﻳﻲ ﺟﻬﺖ اﻧﺠﺎم واﻛـﻨﺶ ‪PCR‬‬
‫‪ 11/4) 8‬درﺻﺪ(‪ ،‬زﺧﻢ ‪ 7/1) 5‬درﺻﺪ( و ﺧﻮن ‪ 2/9) 2‬درﺻﺪ(‬
‫ﺑﻪ ﻟﻮﻟﻪﻫﺎي اﭘﻨﺪورف ﺟﺪﻳﺪ ﻣﻨﺘﻘﻞ ﺷﺪ و ﺑﻪ ﻋﻨـﻮان ‪DNA‬‬
‫ﻧﻤﻮﻧﻪ ﻗﺮار داﺷﺘﻨﺪ‪ .‬ﻣﻘﺎوﻣـﺖ آﻧﺘـﻲ ﺑﻴـﻮﺗﻴﻜﻲ ﺟﺪاﻳـﻪﻫـﺎي‬
‫ﺑﺎﻛﺘﺮي ﺑﻪ ﻛﺎر رﻓﺖ‪ .‬ﺑﺮاي واﻛﻨﺶ ‪ PCR‬ﺑﺎ ﺣﺠـﻢ ﻧﻬـﺎﻳﻲ‬
‫ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﻧﺴﺒﺖ ﺑﻪ ‪ 15‬آﻧﺘﻲ ﺑﻴﻮﺗﻴﻚ در ﺟﺪول ﺷﻤﺎره ‪ 2‬و‬
‫‪ 25‬ﻣﻴﻜﺮوﻟﻴﺘﺮ‪ ،‬از ‪ 12/5‬ﻣﻴﻜﺮوﻟﻴﺘﺮ ‪) Master Mix‬ﺳـﻴﻨﺎﻛﻠﻮن‬
‫ﻧﺘﺎﻳﺞ ‪ PCR‬ژنﻫﺎي ‪ blaTEM ،blaCTX-M‬و ‪blaSHV‬‬
‫اﻳﺮان(‪ 2 ،‬ﻣﻴﻜﺮوﻟﻴﺘﺮ ‪ DNA‬ﺑـﺎﻛﺘﺮي‪ 1 ،‬ﻣﻴﻜﺮوﻟﻴﺘـﺮ از ﻫـﺮ‬
‫در ﺟﺪول ﺷﻤﺎره ‪ 3‬و ﺗﺼﻮﻳﺮ ﺷﻤﺎره ‪ 1‬آﻣﺪه اﺳﺖ‪ .‬در ﻛـﻞ‬
‫ﭘﺮاﻳﻤﺮ و آب ﻣﻘﻄـﺮ دو ﺑـﺎر ﺗﻘﻄﻴـﺮ اﺳـﺘﺮﻳﻞ ﺗـﺎ ﺣﺠـﻢ ‪25‬‬
‫از ﻧﻈﺮ ژﻧﻮﺗﻴﭙﻲ ‪ 19‬اﻳﺰوﻟﻪ )‪ 31/6‬درﺻﺪ( ﻣﻮﻟﺪ ‪ ESBL‬ﺑﻮدﻧﺪ‪.‬‬
‫ﻣﻴﻜﺮوﻟﻴﺘﺮ اﺳﺘﻔﺎده ﺷﺪ‪ .‬ﻣﺮاﺣﻞ دﻣﺎﻳﻲ ‪ PCR‬ﺷﺎﻣﻞ ‪ 5‬دﻗﻴﻘﻪ‬
‫راﺑﻄﻪ ﻣﻌﻨﻲداري ﺑﻴﻦ ژنﻫﺎي ‪ ESBL‬ﺑﺎ ﺟﻨﺴـﻴﺖ )‪(p=0/61‬‬
‫دﻧﺎﭼﻮرﻳﺸﻦ اوﻟﻴـﻪ در ‪ 94‬درﺟـﻪ ﺳـﺎﻧﺘﻲﮔـﺮاد‪ ،‬ﺳـﭙﺲ ‪35‬‬
‫و ﺳﻦ ﺑﻴﻤﺎران )‪ (p=0/59‬وﺟﻮد ﻧﺪاﺷﺖ‪ .‬ﻫﻢﭼﻨﻴﻦ ﺑﻴﻦ ﺷﻴﻮع‬
‫ﺳﻴﻜﻞ ﻃﺒﻖ ﺟﺪول ﺷﻤﺎره ‪ 1‬و در آﺧﺮ ‪ 5‬دﻗﻴﻘﻪ اﮔﺴﺘﻨﺸـﻦ‬
‫ژنﻫﺎي ‪ ESBL‬و ﺑﺨـﺶﻫـﺎي ﺑﻴﻤﺎرﺳـﺘﺎﻧﻲ و ﻧﻴـﺰ ﺑﺴـﺘﺮي و‬
‫در ‪ 72‬درﺟﻪ ﺳﺎﻧﺘﻲ ﮔﺮاد ﺑﻮد‪ .‬ﻣﺤﺼﻮﻻت ‪ PCR‬ﺑﺎ اﺳـﺘﻔﺎده‬
‫ﺳﺮﭘﺎﻳﻲ ﺑﻮدن ﺑﻴﻤﺎران راﺑﻄﻪ ﻣﻌﻨﻲداري ﻧﺒﻮد )‪ .(p=0/8‬اﻣﺎ‬
‫از اﻟﻜﺘﺮوﻓﻮرز ﺑﺎ ژل آﮔﺎرز ﻳﻚ درﺻـﺪ و رﻧـﮓآﻣﻴـﺰي‬
‫ﺑﻴﻦ ژن ‪ CTX-M‬ﺑﺎ ﻣﻘﺎوﻣﺖ ﺑﻪ ﺳﻔﺘﺎزﻳﺪﻳﻢ )‪ (p=0/019‬و‬
‫ﺑﺎ اﺗﻴﺪﻳﻮم ﺑﺮوﻣﺎﻳﺪ ﺑﺎ دﺳﺘﮕﺎه ژل داك ﺑﺮرﺳﻲ ﺷﺪ‪.‬‬
‫ژن ‪ TEM‬ﺑــﺎ ﻣﻘﺎوﻣــﺖ ﺑــﻪ اﻳﻤــﻲﭘــﻨﻢ)‪ (p=0/014‬راﺑﻄــﻪ‬
‫ﻣﻌﻨﻲداري ﺑﺎ آزﻣﻮن ‪ Chi-Square‬ﺑﻪ دﺳﺖ آﻣﺪ )ﺟـﺪول‬ ‫آﻧﺎﻟﻴﺰ آﻣﺎري‬
‫ﺷﻤﺎره ‪.(4‬‬ ‫ﻧﺘﺎﻳﺞ آزﻣﺎﻳﺶﻫـﺎي ﻣﺨﺘﻠـﻒ اﻧﺠـﺎم ﺷـﺪه ﺑـﻪ ﻫﻤـﺮاه‬

‫ﺟﺪول ﺷﻤﺎره ‪ :1‬ﭘﺮاﻳﻤﺮﻫﺎ و ﺳﻴﻜﻞ ﻫﺎي دﻣﺎﻳﻲ ﻣﻮرد اﺳﺘﻔﺎده در ‪PCR‬‬

‫‪35 Cycles‬‬
‫)‪Product size (bp‬‬ ‫‪Extension 72˚C‬‬ ‫‪Annealing 30 Sec‬‬ ‫‪Denaturation94˚C‬‬ ‫)́‪Sequence (5́-3‬‬ ‫‪Primer‬‬

‫‪F:TTTGCGATGTGCAGTACCAGTAA‬‬
‫‪544‬‬ ‫‪40 Sec‬‬ ‫‪51˚C‬‬ ‫‪30Sec‬‬ ‫‪R:CGATATCGTTGGTGGTGCCATA‬‬ ‫‪blaCTX-M‬‬

‫‪F:AGTGCTGCCATAACCATGAGTG‬‬
‫‪431‬‬ ‫‪30 Sec‬‬ ‫‪61˚C‬‬ ‫‪30Sec‬‬ ‫‪R:CTGACTCCCCGTCGTGTAGATA‬‬ ‫‪blaTEM‬‬

‫‪928‬‬ ‫‪60 Sec‬‬ ‫‪64˚C‬‬ ‫‪30 Sec‬‬ ‫‪F:ATTTGTCGCTTCTTTACTCGC‬‬

‫‪blaSHV‬‬
‫‪R:TTTATGGCGTTACCTTTGACC‬‬

‫دوره ﺑﻴﺴﺖ و ﭘﻨﺠﻢ‪ ،‬ﺷﻤﺎره ‪ ، 127‬ﻣﺮداد ‪1394‬‬ ‫ﻣﺠﻠﻪ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻣﺎزﻧﺪران‬ ‫‪68‬‬
 ‫ﻋﻠﻴﺸﺎ اﻛﻴﺎ و ﻫﻤﻜﺎران‬ ‫ﭘﮋوﻫﺸﻲ‬

‫ﺟﺪول ﺷﻤﺎره ‪ :3‬ﻓﺮاواﻧﻲ ﮔﻮﻧﻪ ﻫﺎي ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ و ﻓﺮاواﻧﻲ ژن ﻫﺎي‬ ‫ﺟﺪول ﺷﻤﺎره ‪ :2‬ﻓﺮاواﻧﻲ ﻣﻘﺎوﻣﺖ آﻧﺘﻲ ﺑﻴﻮﺗﻴﻜﻲ ﺟﺪاﻳﻪ ﻫﺎي ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ‬
‫‪ ESBL‬در آن ﻫﺎ‬ ‫ﺑﻪ آﻧﺘﻲ ﺑﻴﻮﺗﻴﻚ ﻫﺎ‬
‫ﻓﺮاواﻧﻲ ژن ﻫﺎي ‪ESBL‬‬ ‫ﺟﻤﻊ ﻣﻘﺎوﻣﺖ‬ ‫‪ 6‬ﺳﻴﺘﺮوﺑﺎﻛﺘﺮﻛﻮﺳﺮي‬ ‫‪ 60‬ﺳﻴﺘﺮوﺑﺎﻛﺘﺮﻓﺮوﻧﺪي‬
‫ﻓﻨﻮﺗﻴﭙﻲ ‪ESBL‬‬ ‫ﮔﻮﻧﻪ ﻫﺎ‬ ‫ﮔﻮﻧﻪ ﻫﺎي‬ ‫آﻧﺘﻲ ﺑﻴﻮﺗﻴﻚ ﻫﺎ‬
‫‪blaCTX-M‬‬ ‫‪blaTEM‬‬ ‫‪blaSHV‬‬
‫ﺗﻌﺪاد)درﺻﺪ(‬ ‫ﺗﻌﺪاد)درﺻﺪ(‬ ‫ﺗﻌﺪاد )درﺻﺪ(‬
‫ﺗﻌﺪاد )درﺻﺪ(‬ ‫ﺗﻌﺪاد )درﺻﺪ(‬ ‫ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ‬ ‫)‪56(84/8‬‬ ‫)‪4(66/7‬‬ ‫)‪52(86/7‬‬ ‫ﺳﻔﺎزوﻟﻴﻦ‬
‫ﺗﻌﺪاد )درﺻﺪ( ﺗﻌﺪاد )درﺻﺪ ﺗﻌﺪاد )درﺻﺪ‬
‫‪(%1/6) 1‬‬ ‫‪(%13/3) 8‬‬ ‫‪(%21/7) 13‬‬ ‫‪(%8/3) 5‬‬ ‫‪(%85/7) 60‬‬ ‫ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﻓﺮوﻧﺪي‬ ‫)‪18(27/3‬‬ ‫)‪2(33/3‬‬ ‫)‪16(26/7‬‬ ‫ﺳﻔﭙﻮدوﻛﺴﻴﻢ‬
‫‪0‬‬ ‫‪0‬‬ ‫‪(%33/3) 2‬‬ ‫‪0‬‬ ‫‪(%8/6) 6‬‬ ‫ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﻛﻮﺳﺮي‬ ‫)‪16(24/2‬‬ ‫)‪3(50‬‬ ‫)‪13(21/7‬‬ ‫ﺳﻔﻮﺗﺎﻛﺴﻴﻢ‬
‫‪0‬‬ ‫‪0‬‬ ‫‪0‬‬ ‫‪0‬‬ ‫‪(%5/7)4‬‬ ‫ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﺑﺮاﻛﺌﻲ‬ ‫)‪15(22/7‬‬ ‫)‪3(50‬‬ ‫)‪12(20‬‬ ‫ﺳﻔﺘﺎزﻳﺪﻳﻢ‬
‫‪(%1/4) 1‬‬ ‫‪(%11/4) 8‬‬ ‫‪(%21/4) 15‬‬ ‫‪(%7/1) 5‬‬ ‫‪(%100) 70‬‬ ‫ﺟﻤﻊ ﻛﻞ‬ ‫)‪13(19/6‬‬ ‫)‪3(50‬‬ ‫)‪10(16/7‬‬ ‫ﺳﻔﺘﺮﻳﺎﻛﺴﻮن‬
‫)‪47(71/2‬‬ ‫)‪4(66/7‬‬ ‫)‪43(71/7‬‬ ‫آﻣﭙﻲ ﺳﻴﻠﻴﻦ‬
‫)‪3(4/5‬‬ ‫)‪1(16/7‬‬ ‫)‪2(3/3‬‬ ‫ﭘﻴﭙﺮاﺳﻴﻠﻴﻦ‪/‬ﺗﺎزوﺑﺎﻛﺘﺎم‬
‫ﺟﺪول ﺷﻤﺎره ‪ : 4‬ﻣﻘﺎﻳﺴﻪ ﺣﺴﺎﺳﻴﺖ اﻳﺰوﻟﻪ ﻫﺎ ﺑﻪ ﺳﻔﺘﺎزﻳﺪﻳﻢ و اﻳﻤﻲ‬
‫)‪1(1/5‬‬ ‫)‪1(16/7‬‬ ‫)‪0(0‬‬ ‫اﻳﻤﻲ ﭘﻨﻢ‬
‫ﭘﻨﻢ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ داﺷﺘﻦ ژن ﻫﺎي ‪ CTXM‬و ‪TEM‬‬ ‫)‪1( 1/5‬‬ ‫)‪1(16/7‬‬ ‫)‪0( 0‬‬ ‫ارﺗﺎﭘﻨﻢ‬

‫ﺳﻄﺢ‬ ‫‪CTXM gene‬‬ ‫‪TEM gene‬‬ ‫ﺣﺴﺎﺳﻴﺖ‬ ‫ﻧﻮع‬ ‫)‪1(1/5‬‬ ‫)‪1(16/7‬‬ ‫)‪0(0‬‬ ‫ﻣﺮوﭘﻨﻢ‬

‫ﻣﻌﻨﻲ داري‬ ‫ﻣﺜﺒﺖ‬ ‫ﻣﻨﻔﻲ‬ ‫ﻣﺜﺒﺖ‬ ‫ﻣﻨﻔﻲ‬ ‫آﻧﺘﻲ ﺑﻴﻮﺗﻴﻜﻲ‬ ‫آﻧﺘﻲ ﺑﻴﻮﺗﻴﻚ‬ ‫)‪14( 21/2‬‬ ‫)‪2(33/3‬‬ ‫)‪12( 20‬‬ ‫آزﺗﺮوﻧﺎم‬

‫‪3‬‬ ‫‪5‬‬ ‫ﻣﻘﺎوم‬ ‫)‪13(19/7‬‬ ‫)‪1(16/7‬‬ ‫)‪12(20‬‬ ‫ﺗﻮﺑﺮاﻣﺎﻳﺴﻴﻦ‬

‫‪0/014‬‬ ‫اﻳﻤﻴﭙﻨﻢ‬ ‫)‪6(9/1‬‬ ‫)‪2(33/3‬‬ ‫)‪4(6/7‬‬ ‫ﺟﻨﺘﺎﻣﺎﻳﺴﻴﻦ‬
‫‪5‬‬ ‫‪57‬‬ ‫ﺣﺴﺎس‬
‫)‪24(36/4‬‬ ‫)‪3(50‬‬ ‫)‪21(35‬‬ ‫ﻛﻮﺗﺮﻳﻤﻮﻛﺴﺎزول‬
‫‪8‬‬ ‫‪12‬‬ ‫ﻣﻘﺎوم‬
‫‪0/019‬‬ ‫ﺳﻔﺘﺎزﻳﺪﻳﻢ‬ ‫)‪14(21/2‬‬ ‫)‪4(66/7‬‬ ‫)‪10(16/7‬‬ ‫ﺳﻴﭙﺮوﻓﻠﻮﻛﺴﺎﺳﻴﻦ‬
‫‪7‬‬ ‫‪42‬‬ ‫ﺣﺴﺎس‬

‫ﺑﺤﺚ‬
‫ﮔﻮﻧﻪﻫﺎي ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﺗﻤﺎﻳﻞ ﺑـﻪ اﻳﺠـﺎد ﻋﻔﻮﻧـﺖﻫـﺎي‬
‫ﻓﺮﺻﺖ ﻃﻠﺐ ﺑﻴﻤﺎرﺳﺘﺎﻧﻲ ﺑﺎ ﻣﻘﺎوﻣﺖ ﺑﺎﻻي آﻧﺘـﻲﺑﻴـﻮﺗﻴﻜﻲ‬
‫دارﻧﺪ‪ .‬ژنﻫﺎي ﻣﺨﺘﻠﻒ ‪ ESBL‬در ﺳﺎلﻫﺎي اﺧﻴﺮ در ﻧﻘﺎط‬
‫ﻣﺨﺘﻠﻒ ﺟﻬﺎن در ﻣﻴﺎن اﻧﺘﺮوﺑﺎﻛﺘﺮﻳﺎﺳﻪﻫﺎ از ﺟﻤﻠﻪ ﮔﻮﻧﻪﻫـﺎي‬
‫ﺳــﻴﺘﺮوﺑﺎﻛﺘﺮ ﮔﺴــﺘﺮش ﻳﺎﻓﺘــﻪاﻧـﺪ)‪ .(17-19‬در اﻳــﻦ ﻣﻄﺎﻟﻌــﻪ‬
‫ﺑﻴﺶﺗﺮﻳﻦ ﻣﻮارد ﻋﻔﻮﻧﺖ ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ در ﺑﻴﻤﺎران زن ﻣﻴﺎﻧﺴﺎل‬
‫و ﺑﻴﺶﺗﺮﻳﻦ ﻧﻤﻮﻧﻪﻫﺎ ﻣﺮﺑـﻮط ﺑـﻪ ادرار و ﺳـﭙﺲ ﺗﺮﺷـﺤﺎت‬
‫ﻣﺠﺎري ﺗﻨﻔﺴـﻲ ﺑـﻮد‪ .‬ﺑـﺎ ﺗﻮﺟـﻪ ﺑـﻪ ﺷـﻴﻮع ﺑـﺎﻻﺗﺮ ﻋﻔﻮﻧـﺖ‬
‫ادراري در ﺧﺎﻧﻢﻫﺎ‪ ،‬ﺷﻴﻮع ﺑﻴﺶﺗﺮ ﻋﻔﻮﻧﺖ ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ در‬
‫آنﻫﺎ ﻗﺎﺑﻞ ﺗﻮﺟﻴﻪ اﺳﺖ‪ .‬ﺑﻴﺶﺗﺮﻳﻦ اﻳﺰوﻟﻪﻫﺎي ﺟﺪا ﺷﺪه از‬
‫ﻧﻤﻮﻧﻪﻫﺎي ﺑﺎﻟﻴﻨﻲ در ﺑﻴﻦ ﮔﻮﻧﻪﻫـﺎي ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ ﻣﺘﻌﻠـﻖ ﺑـﻪ‬
‫ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﻓﺮوﻧﺪي ﺑﻮد ﻛﻪ اﻳﻦ ﻣﻴـﺰان ﻓﺮاواﻧـﻲ ﺑـﺎ ﻧﺘـﺎﻳﺞ‬
‫ﻣﻄﺎﻟﻌﺎت دﻳﮕﺮ ﻫﻤﺨﻮاﻧﻲ دارد و ﺑـﻪ ﻧﻈـﺮ ﻣـﻲرﺳـﺪ ﮔﻮﻧـﻪ‬
‫ﻏﺎﻟــﺐ در اﻳﺠــﺎد ﻋﻔﻮﻧــﺖﻫـﺎي ﺑﻴﻤﺎرﺳــﺘﺎﻧﻲ در ﻛﺮﻣﺎﻧﺸــﺎه‬
‫ﺑﺎﺷﺪ)‪ .(21،20‬در ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻣﻘﺎوﻣﺖ آﻧﺘﻲﺑﻴﻮﺗﻴﻜﻲ اﻳﺰوﻟﻪﻫﺎ‬
‫ﺑــﻪ آﻧﺘــﻲﺑﻴﻮﺗﻴــﻚﻫــﺎي ﻧﺴــﻞ ﺳــﻮم ﺳﻔﺎﻟﻮﺳــﭙﻮرﻳﻦﻫــﺎ و‬ ‫ﺗﺼﻮﻳﺮ ﺷﻤﺎره ‪ :1‬ﻧﺘﺎﻳﺞ ‪ PCR‬ژن ﻫﺎي ‪ blaTEM ،blaCTX-M‬و‬
‫ﻓﻠﻮروﻛﻴﻨﻮﻟﻮنﻫﺎ از ﻣﻄﺎﻟﻌﺎت دﻳﮕﺮ ﭘﺎﻳﻴﻦ ﺗﺮ ﺑـﻮد‪ .‬ﻣـﺜﻼً در‬ ‫‪ -1:( blaCTX-M): blaSHV‬ﻣﺎرﻛﺮ )‪ -2 ،(100 bp‬ﻛﻨﺘﺮل ﻣﺜﺒﺖ‬
‫)‪ -3 ،(544bp‬ﻛﻨﺘﺮل ﻣﻨﻔﻲ‪ -4 ،‬ﻧﻤﻮﻧﻪ ﻣﺜﺒﺖ )‪:(blaTEM) :،(544bp‬‬
‫ﻣﻄﺎﻟﻌﺎﺗﻲ ﻛﻪ در ﻫﻨﺪوﺳﺘﺎن و ژاﭘﻦ اﻧﺠﺎم ﺷﺪ‪ ،‬ﺑـﻴﺶﺗـﺮﻳﻦ‬
‫‪ -1‬ﻣﺎرﻛﺮ )‪ -2 ،(100 bp‬ﻛﻨﺘﺮل ﻣﺜﺒﺖ )‪ -3 ،(431bp‬ﻧﻤﻮﻧﻪ ﻣﺜﺒﺖ‬
‫ﻣﻘﺎوﻣﺖ ﺑﻪ ﺳﻔﻮﺗﺎﻛﺴﻴﻢ )‪ 89‬درﺻـﺪ(‪ ،‬ﺳـﻔﺘﺎزﻳﺪﻳﻢ )‪81/5‬‬ ‫)‪ -1 :(blaSHV) :،(431bp‬ﻣﺎرﻛﺮ )‪ -2 ،(100 bp‬ﻛﻨﺘﺮل ﻣﺜﺒﺖ‬
‫درﺻﺪ(‪ ،‬ﺳﻴﭙﺮوﻓﻠﻮﻛﺴﺎﺳـﻴﻦ )‪ 75/3‬درﺻـﺪ( و آزﺗﺮﺋﻮﻧـﺎم‬ ‫)‪ -3 ،(928bp‬ﻛﻨﺘﺮل ﻣﻨﻔﻲ‪ -4 ،‬ﻧﻤﻮﻧﻪ ﻣﺜﺒﺖ )‪.(928bp‬‬

‫‪69‬‬ ‫دوره ﺑﻴﺴﺖ و ﭘﻨﺠﻢ‪ ،‬ﺷﻤﺎره ‪ ، 127‬ﻣﺮداد ‪1394‬‬ ‫ﻣﺠﻠﻪ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻣﺎزﻧﺪران‬
‫ﺑﺮرﺳﻲ دﻳﮕﺮي درﻛﺮه ﺟﻨﻮﺑﻲ ﺑـﻴﻦ ‪ 20/6‬ﺗـﺎ ‪ 4/9‬درﺻـﺪ‬
‫ﮔﺰارش ﮔﺮدﻳﺪ‪ .‬ﻣﻄﺎﻟﻌﺎت دﻳﮕﺮي در آﻣﺮﻳﻜـﺎ ﻧﻴـﺰ ﺷـﻴﻮع‬
‫‪ ESBL‬ﻫــﺎ در ﺳــﻴﺘﺮوﺑﺎﻛﺘﺮ ﻓﺮوﻧــﺪي ‪ 0/9‬درﺻــﺪ و در‬
‫ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﻛﻮﺳﺮي ‪ 3/5‬درﺻﺪ ﺑﻪ دﺳﺖ آﻣﺪه اﺳﺖ)‪.(25‬‬
‫ﺗﻔــﺎوت در ﻧﺘــﺎﻳﺞ اﻳــﻦ ﻣﻄﺎﻟﻌــﺎت ﻣــﻲﺗﻮاﻧــﺪ ﻧﺸــﺎن دﻫﻨــﺪه‬
‫ﺗﻔﺎوت در ﮔﺴـﺘﺮش ژنﻫـﺎي ‪ ESBL‬در ﻣﻨـﺎﻃﻖ ﻣﺨﺘﻠـﻒ‬
‫ﺟﻬﺎن ﺑﺎﺷﺪ و ﺑﻪ ﻧﻈﺮ ﻣﻲرﺳﺪ در ﻛﺸﻮرﻫﺎي در ﺣﺎل ﺗﻮﺳـﻌﻪ‬
‫ﺷﻴﻮع ﺑﺎﻻﺗﺮ ﺑﺎﺷـﺪ‪ .‬از ﻧﻈـﺮ ﻣﻴـﺰان ﻓﺮاواﻧـﻲ اﻧـﻮاع ژنﻫـﺎي‬
‫‪ ESBL‬در ﺳــﻴﺘﺮوﺑﺎﻛﺘﺮ در ﻣﻄﺎﻟﻌــﻪ ﻣــﺎ ﺑــﻴﺶﺗــﺮﻳﻦ ﺷــﻴﻮع‬
‫ژنﻫﺎي ‪ ESBL‬ﻣﺮﺑـﻮط ﺑـﻪ ژن ‪ blaCTX-M‬ﺑـﻮد ﻛـﻪ ﺑـﺎ‬
‫ﻧﺘــﺎﻳﺞ اﻛﺜــﺮ ﻣﻄﺎﻟﻌــﺎت ﻫﻤﺨــﻮاﻧﻲ دارد‪ .‬در ﻣﻄﺎﻟﻌــﻪ اي در‬
‫ﻟﻬﺴﺘﺎن‪ ،‬ﺑﻴﺶﺗﺮﻳﻦ ﻓﺮاواﻧﻲ ﺑﺎ ‪ 25‬درﺻﺪ ﺑﺮاي ‪ CTX-M‬و‬
‫ﺳﭙﺲ ‪ SHV‬ﺑﺎ ‪ 4/5‬درﺻﺪ ﺑﻮد)‪ .(25،24‬در ﻣﻄﺎﻟﻌﻪي دﻳﮕﺮي‬
‫در ﺗﺎﻳﻠﻨﺪ‪ ،‬ﺑﻴﺶﺗﺮﻳﻦ ﺷﻴﻮع در ژنﻫﺎي ‪ CTX-M‬و ‪TEM‬‬
‫ﮔــﺰارش ﺷــﺪ ﻛــﻪ از اﻳــﻦ ﻟﺤــﺎظ ﺑــﺎ ﻧﺘــﺎﻳﺞ ﻣــﺎ ﺳــﺎزﮔﺎر‬
‫اﺳﺖ)‪ .(26‬از ﻃﺮف دﻳﮕﺮ در ﻣﻄﺎﻟﻌﺎت دﻳﮕﺮي ﺷـﻴﻮع ژن‬
‫‪ SHV‬از ژنﻫﺎي دﻳﮕﺮ ﺑﺎﻻﺗﺮ ﺑﻮده اﺳﺖ‪ .‬ﻣـﺜﻼً در ﻣﻄﺎﻟﻌـﻪاي‬
‫در ﻛﺎﻧﺎدا ﺑـﺮ روي ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ‪ ،‬ﺑـﻴﺶﺗـﺮﻳﻦ ﻣﻴـﺰان ﺷـﻴﻮع‬
‫ژنﻫــﺎي ‪ ESBL‬ﻣﺮﺑــﻮط ﺑــﻪ ‪ 22/2) SHV‬درﺻــﺪ( ﺑــﻮد‪.‬‬
‫ﻫﻢﭼﻨﻴﻦ در ژاﭘﻦ ﻣﻴﺰان ﺷﻴﻮع اﻳﻦ ژن ‪ 19/3‬درﺻـﺪ و در‬
‫ﻛـﺮه ﺟﻨـﻮﺑﻲ ‪ 4/9‬درﺻـﺪ ﮔــﺰارش ﺷـﺪه اﺳـﺖ)‪ .(27‬اﻳــﻦ‬
‫ﺗﻔﺎوت در ﻧﺘﺎﻳﺞ ﺑﻴﺎﻧﮕﺮ ﺗﻔـﺎوت در اﻧﺘﺸـﺎر ژنﻫـﺎي ﻣـﻮرد‬
‫ﺑﺮرﺳﻲ در ﻣﻨﺎﻃﻖ ﻣﺨﺘﻠﻒ دﻧﻴﺎ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫در ﭘﺎﻳﺎن ﻣﻲﺗﻮان ﻧﺘﻴﺠـﻪﮔﻴـﺮي ﻛـﺮد ﻛـﻪ ﻧﺘـﺎﻳﺞ اﻳـﻦ‬
‫ﻣﻄﺎﻟﻌﻪ ﻧﺸﺎن داد ﻛﻪ درﺻﺪ ﺑﺎﻻﻳﻲ از ﺳﻴﺘﺮوﺑﺎﻛﺘﺮﻫﺎي ﺟﺪا‬
‫ﺷــﺪه داراي ژنﻫــﺎي ‪ ESBL‬ﻫﺴــﺘﻨﺪ و از ﻣﻴــﺎن آنﻫــﺎ ژن‬
‫‪ blaCTX-M‬ﺑــﻴﺶﺗــﺮﻳﻦ ﻓﺮاواﻧــﻲ را در اﻳــﻦ ﻣﻨﻄﻘــﻪ دارا‬
‫ﻣــﻲﺑﺎﺷــﺪ‪ .‬از ﻟﺤــﺎظ ﻣﻘﺎوﻣــﺖ آﻧﺘــﻲﺑﻴــﻮﺗﻴﻜﻲ‪ ،‬ﻛــﻢﺗــﺮﻳﻦ‬
‫ﻣﻘﺎوﻣﺖ ﺑﻪ ﻛﺎرﺑﺎﭘﻨﻢﻫﺎ ﻣﺸﺎﻫﺪه ﺷﺪ‪ .‬وﻟـﻲ در اﻳـﻦ ﺗﺤﻘﻴـﻖ‬
‫ﻣﻘﺎوﻣﺖ ﺑـﺎﻻﻳﻲ ﺑـﻪ آﻧﺘـﻲﺑﻴﻮﺗﻴـﻚﻫـﺎﻳﻲ ﻣﺜـﻞ ﺳـﻔﺎزوﻟﻴﻦ‪،‬‬
‫آﻣﭙﻲﺳﻴﻠﻴﻦ و ﻛﻮﺗﺮﻳﻤﻮﻛﺴﺎزول دﻳﺪه ﺷـﺪ‪ ،‬اﻣـﺎ در ﻣـﻮرد‬
‫ﺳﻔﺎﻟﻮﺳﭙﻮرﻳﻦﻫﺎي ﻧﺴﻞ ﺳﻮم ﻣﻘﺎوﻣﺖ ﭘـﺎﻳﻴﻦﺗـﺮ ﺑـﻮد‪ .‬ﺑـﻴﻦ‬
‫ﻓﺮاواﻧﻲ ﻓﻨﻮﺗﻴﭙﻲ و ژﻧﻮﺗﻴﭙﻲ ‪ ESBL‬در اﻳﺰوﻟﻪﻫﺎي ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ‬
‫اﺧﺘﻼف زﻳﺎدي وﺟﻮد داﺷـﺖ ﻛـﻪ ﻣﻤﻜـﻦ اﺳـﺖ ﻧﺸـﺎﻧﮕﺮ‬
‫دوره ﺑﻴﺴﺖ و ﭘﻨﺠﻢ‪ ،‬ﺷﻤﺎره ‪ ، 127‬ﻣﺮداد ‪1394‬‬
‫)‪ 74/7‬درﺻﺪ( و ﻛﻢﺗﺮﻳﻦ ﻣﻘﺎوﻣﺖ ﺑـﻪ آﻣﻴﻜﺎﺳـﻴﻦ )‪17/9‬‬
‫درﺻﺪ(‪ ،‬ﺟﻨﺘﺎﻣﺎﻳﺴﻴﻦ )‪ 22/4‬درﺻـﺪ(ﮔـﺰارش ﺷـﺪ‪ .‬ﻧﺘـﺎﻳﺞ‬
‫اﻳﻦ ﻣﻄﺎﻟﻌﺎت در ﻣـﻮرد آﻣﻴﻨﻮﮔﻠﻴﻜﻮزﻳـﺪﻫﺎ ﺑـﻪ ﻣﻄﺎﻟﻌـﻪ ﻣـﺎ‬
‫ﻧﺰدﻳﻚ اﺳﺖ)‪ .(22 ،19‬ﻃـﻲ ﻣﻄﺎﻟﻌـﻪاي در ﺳـﺎل ‪ 2014‬در‬
‫اﻳﺮان ﺑﺮ روي ‪ 12‬اﻳﺰوﻟﻪ ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ‪ ،‬ﺑﻴﺶﺗـﺮﻳﻦ ﻣﻘﺎوﻣـﺖ‬
‫آﻧﺘﻲﺑﻴﻮﺗﻴﻜﻲ ﺑﻪ ﺗﺘﺮاﺳﺎﻳﻜﻠﻴﻦ )‪ 92‬درﺻﺪ(‪ ،‬ﻧﺎﻟﻴﺪﻳﻜﺴـﻴﻚ‬
‫اﺳﻴﺪ )‪ 83‬درﺻﺪ(‪ ،‬ﺟﻨﺘﺎﻣﺎﻳﺴﻴﻦ )‪ 67‬درﺻﺪ( و ﺗﻮﺑﺮاﻣﺎﻳﺴـﻴﻦ‬
‫)‪ 50‬درﺻﺪ( دﻳﺪه ﺷﺪ ﻛﻪ از ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﺑﺎﻻﺗﺮ ﺑﻮد‪ .‬از‬
‫ﻃﺮﻓــﻲ از ‪ 12‬اﻳﺰوﻟــﻪ ﺳــﻴﺘﺮوﺑﺎﻛﺘﺮ‪ 3 ،‬اﻳﺰوﻟــﻪ )‪ 25‬درﺻــﺪ(‬
‫‪ ESBL‬ﻣﺜﺒــﺖ ﺑﻮدﻧــﺪ ﻛــﻪ اﻳــﻦ ﻧﺘﻴﺠــﻪ ﺑــﺎ ﻳﺎﻓﺘــﻪﻫــﺎي ﻣــﺎ‬
‫ﻫﻤﺨــﻮاﻧﻲ دارد)‪ .(23‬از ﺳــﻮي دﻳﮕــﺮ در ﻣﻄﺎﻟﻌــﻪ ﻣــﺎ ﺑــﻴﻦ‬
‫ﻓﺮاواﻧﻲ ﻓﻨﻮﺗﻴﭙﻲ و ژﻧﻮﺗﻴﭙﻲ ‪ ESBL‬در اﻳﺰوﻟﻪﻫﺎي ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ‬
‫اﺧﺘﻼف ﺑﺎﻻﻳﻲ وﺟﻮد داﺷـﺖ ﻛـﻪ ﻣﻤﻜـﻦ اﺳـﺖ ﻧﺸـﺎﻧﮕﺮ‬
‫ﻋﺪم ﺑﻴﺎن ژنﻫﺎي ‪ ESBL‬در اﻳﺰوﻟﻪﻫﺎي ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﺑﺎﺷـﺪ‬
‫و اﻳﻦ ﭘﺪﻳﺪه ﺗﺎ ﺣﺪي ﻣﻘﺎوﻣﺖ ﭘﺎﻳﻴﻦﺗﺮ اﻳﺰوﻟﻪﻫـﺎ را ﻧﺴـﺒﺖ‬
‫ﺑﻪ ﺳﻔﺎﻟﻮﺳﭙﻮرﻳﻦﻫﺎي ﻧﺴﻞ ﺳﻮم ﺗﻮﺟﻴﻪ ﻣﻲﻛﻨﺪ‪ .‬در ﻣﻄﺎﻟﻌـﻪ‬
‫ﻣﺎ ﺷﻴﻮع ﻧﺴـﺒﺘﺎً ﺑـﺎﻻﻳﻲ از ژنﻫـﺎي ‪ ESBL‬در ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ‬
‫ﻓﺮوﻧﺪي وﺟﻮد داﺷﺖ ﻛـﻪ ﺗﺎﻳﻴـﺪي ﺑـﺮ ﮔﺴـﺘﺮش ژنﻫـﺎي‬
‫ﻣﻘﺎوﻣﺖ در اﻳﻦ ﭘﺎﺗﻮژن ﻓﺮﺻﺖ ﻃﻠﺐ اﺳﺖ‪ .‬در ﻣﻄﺎﻟﻌـﻪاي‬
‫در ﻟﻬﺴــﺘﺎن از ﻣﺠﻤــﻮع ‪ 2388‬اﻳﺰوﻟــﻪ اﻧﺘﺮوﺑﺎﻛﺘﺮﻳﺎﺳــﻪ ﺑــﺎ‬
‫ﺑﻴﺶﺗﺮﻳﻦ ﻓﺮاواﻧﻲ ﻧﻤﻮﻧﻪﻫﺎي ادراري‪ 44،‬ﻧﻤﻮﻧـﻪ ﺑـﻪ ﻋﻨـﻮان‬
‫ﺳﻴﺘﺮوﺑﺎﻛﺘﺮ ﻓﺮوﻧﺪي ﮔـﺰارش ﺷـﺪ ﻛـﻪ از اﻳـﻦ ﺗﻌـﺪاد ‪13‬‬
‫)‪ 29/5‬درﺻﺪ( ﻣﻮرد آنﻫﺎ داراي ژنﻫﺎي ‪ ESBL‬ﺑﻮدﻧـﺪ‪.‬‬
‫در ﻣﻄﺎﻟﻌﻪاي دﻳﮕﺮ در ﺗﺎﻳﻠﻨـﺪ از ‪ 105‬اﻳﺰوﻟـﻪ ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ‬
‫‪ 18/7‬درﺻﺪ ﺣﺎوي ژنﻫﺎي ‪ ESBL‬ﺑﻮدﻧﺪ‪ .‬در ﻣﻄﺎﻟﻌـﻪاي‬
‫در ﻫﻨﺪوﺳﺘﺎن ‪ 37‬درﺻﺪ اﻳﺰوﻟـﻪﻫـﺎي ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ ‪ESBL‬‬
‫ﻣﺜﺒﺖ ﺑﻮدﻧﺪ)‪ .(22،25،24‬ﻧﺘﺎﻳﺞ اﻳﻦ ﻣﻄﺎﻟﻌﺎت ﺑﺎ ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ‬
‫ﻣﺎ ﻣﺸﺎﺑﻬﺖ دارد‪ .‬اﻣﺎ در ﻣﻄﺎﻟﻌﺎت دﻳﮕﺮ ﻣﻴـﺰان ﭘـﺎﻳﻴﻦﺗـﺮي‬
‫ﺑﺮاي ﺷﻴﻮع ‪ ESBL‬در اﻳﺰوﻟـﻪﻫـﺎي ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ ﮔـﺰارش‬
‫ﺷﺪه اﺳﺖ‪ .‬ﻣﺜﻼً در ﻣﻄﺎﻟﻌﻪاي ﻛﻪ در ﺳﺎل ‪ 1996-1997‬ﺑﺮ‬
‫روي اﻳﺰوﻟﻪﻫﺎي اﻧﺘﺮوﺑﺎﻛﺘﺮﻳﺎﺳﻪ ﺣﺎﺻﻞ از ﺑﻴﻤﺎران ﺑﺴـﺘﺮي‬
‫ﺻﻮرت ﮔﺮﻓﺖ‪ 11/4 ،‬درﺻﺪ از اﻳﺰوﻟـﻪﻫـﺎي ﺳـﻴﺘﺮوﺑﺎﻛﺘﺮ‬
‫ﻓﺮوﻧﺪي‪ ESBL ،‬ﻣﺜﺒﺖ ﺑﻮدﻧﺪ)‪ .(19‬ﻫﻢﭼﻨﻴﻦ در ﻣﻄﺎﻟﻌـﻪاي‬
‫در ژاﭘﻦ ﺷﻴﻮع ‪ ESBL‬ﻫـﺎ ‪0/2‬درﺻـﺪ ﮔـﺰارش ﺷـﺪ و در‬
‫ﻣﺠﻠﻪ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻣﺎزﻧﺪران‬ ‫‪70‬‬
‫ﻋﻠﻴﺸﺎ اﻛﻴﺎ و ﻫﻤﻜﺎران‬
‫ﺳﭙﺎﺳﮕﺰاري‬
‫ﺑﺪﻳﻦوﺳﻴﻠﻪ از ﻫﻤﻜﺎري ﭘﺮﺳﻨﻞ آزﻣﺎﻳﺸﮕﺎه ﻣﻴﻜﺮوب‬
‫ﺷﻨﺎﺳــﻲ داﻧﺸــﻜﺪه ﭘﺰﺷــﻜﻲ ﻛﺮﻣﺎﻧﺸــﺎه ﺗﻘــﺪﻳﺮ و ﺗﺸــﻜﺮ‬
.‫ﻣﻲﮔﺮدد‬
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73 1394 ‫ ﻣﺮداد‬، 127 ‫ ﺷﻤﺎره‬،‫دوره ﺑﻴﺴﺖ و ﭘﻨﺠﻢ‬ ‫ﻣﺠﻠﻪ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻣﺎزﻧﺪران‬