<p>Uvod: U našoj zemlji nema smernica za lečenje bakterijskih infekcija u tercijarnim zdravstvenim ustanovama. Odabir antibakterijskih lekova je empirijski, što nije uvek u skladu sa preporučenom terapijom prema međunarodnim smernicama. Zbog toga su na Klinici za infektivne bolesti Kliničkog centra Vojvodine u januaru 2013. godine usvojeni međunarodni protokoli i primenjivani za lečenje infektivnih bolesti bakterijske etiologije. Cilj istraživanja bio je da se ispita i uporedi efikasnost lečenja pojedinih antibiotskih tretmana za lečenja infektivnih bolesti bakterijske etiologije prema kliničkom iskustvu ordinirajućeg lekara, prema međunarodno prihvaćenim protokolima i prema modifikovanim međunarodnim protokolima na osnovu stanja lokalne rezistencije. Materijal i metode: Ispitivanje je bilo retrospektivno-prospektivno u trajanju od tri godine od 01.01.2012-31.12.2014.godine, sprovedeno je na Klinici za infektivne bolesti Kliničkog centra Vojvodine. U studiju je uključeno 1147 pacijenata sa dijagnozom infektivne bolesti bakterijske etiologije (sepsa, infekcija urinarnog trakta, bakterijski meningitis, infekcije kože i mekih tkiva, bakterijski tonzilofaringitisi, pneumonija, febrilni gastroenteritis i spondilodiscitis). U retrospektivnom delu, tokom 2012. godine ustanovljena je efikasnost lečenja prema kliničkom iskustvu ordinirajućeg lekara, kod 459 pacijenata. U drugom delu ispitivanja koje je bilo prospektivno, tokom 2013. godine, kod 487 pacijenata, ustanovljena je efikasnost lečenja prema međunarodnim protokolima i upoređena sa lečenjem prema kliničkom iskustvu ordinirajućeg lekara. Tokom 2012. i 2013. godine, ustanovljena je struktura uzročnika i rezistencija na antimikrobne lekove, i prema stanju lokalne rezistencija modifikovani su međunarodni protkoli i primenjivani su tokom 2014. godine. U trećem delu ispitivanja koje je bilo prospektivno, tokom 2014. godine, kod 201 pacijenta ustanovljena je efikasnost lečenja prema modifikovanim međunarodnim protokolima i upoređena sa lečenjem prema usvojenim međunarodnim protokolima. Efikasnost lečenja praćena je na osnovu vrednosti telesne temperature i na osnovu laboratorijskih parametara (leukocita, C reaktivnog proteina, fibrinogena, sedimentacije eritrocita i prokalcitonina), prvog i sedmog dana hospitalizacije. Za upoređivanje efikasnosti terapijskih režima napravljen je sistem skorovanja telesne temperature i laboratorijskih parametara. Za statističku obradu podataka korišćen je programski paket Statistical Package for Social Sciences - SPSS 21. Statistički značajnim se smatraju vrednosti nivoa značajnosti p<0.05. Rezultati: Praćenjem rezistencija bakterija u našoj sredini modifikovani su međunarodni protokoli za lečenje infekcija izazvanih E.coli i S aureus-om. Rezistencija E. coli iz urinokultura tokom 2012. i 2013. godine na ciprofloksacin (koji je preporučen prema međunarodnim protokolima za lečenje infekcija urinarnog trakta) je bila u 2012. godini 38,8% i u 2013. godini 57,1%, a na levofloksacin 27,7% u 2012. godini i u 2013. godini 28,6%. Rezistencija S. aureus-a izolovanog iz brisa rana na cefazolin (koji je preporučen prema međunarodnim protokolima za lečenje infekcija kože i mekih tkiva) u prve dve godine ispitivanja bila je 25% a na klindamicin nije zabeležena rezistencija. Rezistencija S. aureus-a na cefazolin (koji je preporučen prema međunarodnim protokolima za lečenje bakterijskih tonzilofaringitisa) iz brisa grla bila je u 2012. godini 18,1%, u 2013. godini 14,2% a na klindamicin u ovom periodu nije zabeležena rezistencija. Tako da je preporuka u modifikovanom kliničkom protokolu za lečenje infekcija urinarnog trakta levofloksacin, za lečenje bakterijskih tonzilofaringitisa i lečenje infekcija kože i mekih tkiva izazvanih S aureus-om klindamicin.Poredeći ukupan skor kliničkih i laboratorijskih parametara, lečenje pacijenata prema usvojenim međunarodnim protokolima, statistički značajno je efikasnije u odnosu na lečenje prema kliničkom iskustvu lekara kod lečenja pacijenata sa infekcijom urinarnog trakta (p=0,034) i infekcijom kože i mekih tkiva (p=0,032). U lečenju ostalih ispitivanih bakterijskih infekcija prema kliničkom iskustvu lekara i usvojenim međunarodnim protokolima nema statički značajne razlike (p>0,05). Lečenje pacijenata sa infekcijom urinarnog trakta, prema modifikovanim međunarodnim protokolima je statistički značajno efikasnije u odnosu na efikasnost lečenja prema usvojenim međunarodnim protokolima (p=0,025) poredeći ukupan skor kliničkih i laboratorijskih parametara. Lečenje pacijenata sa tonzilofaringitisima i infekcijama kože i mekih tkiva prema modifikovanim međunarodnim protokolima podjednako je efikasno u odnosu na lečenje prema usvojenim međunarodnim protokolima (p=0,100) poredeći ukupan skor kliničkih i laboratorijskih parametara. Zaključak: Upoređivanjem dobijenih rezultata, omogućeno je određivanje najoptimalnijeg načina lečenja bolesti bakterijske etiologije, uvažavajući preporuke prema međunarodnim smernicama. Dobijeni rezultati ukazuju na to da je praćenjem lokalne strukture uzročnika i stanja lokalne rezistencije omogućeno određivanje optimalnijeg načina lečenja infekcija urinarnog trakta i infekcije kože i mekih tkiva, uvažavajući međunarodne preporuke i modifikaciju međunarodnih smernica prema stanju rezistencija bakterija na antimikrobne lekove u našoj sredini</p> / <p>Introduction:In our country,there are noguidelines for the treatment of bacterial infections in tertiary health institutions. The choice of antibiotic is empirical and it does not always comply with the recommended treatment according to international guidelines. For this reason, international protocols were adopted at the Clinic for infectious diseases of the Clinical Center of Vojvodinain January 2013. and implemented in therapy of infectious diseases caused by bacteria. The aim of the study was to compare different regimens and to evaluate their effectiveness in therapy of the bacterial infections: one based on the clinical experience of the prescribing physician, another based on international guidelines and the third, modified international protocoladapted to comply with the local antibacterial resistance. Material and methods: Thisretrospective-prospective study was conducted at the Clinic for Infectious Diseases of the Clinical Center of Vojvodina and it covered the period of three years, from 01.01.2012.-31.12.2014. 1,147 patients diagnosed with infectious diseases of bacterial etiology (sepsis, urinary tract infections, bacterial meningitis, skin and soft tissue infections, bacterial tonsillopharyngitis, pneumonia, febrile gastroenteritis and spondylodiscitis) were included in the study. In the first, retrospective part of the study, the efficacy of therapy based on the clinical experience of the prescribing physician was analyzed from medical records of 459 patients treated in 2012. In 2013, during the second, prospective part of the study, the efficacy of treatment according to the international guidelines was evaluated in 487 patients and the results were compared to the data obtained from the patients treated according to the clinical experience of the prescribing physician. The types of organism isolated in 2012/2013 were analyzed as well as their resistance to antimicrobials, the international protocols were subsequently modified according to the state of local resistance and implemented during 2014. In 2014, during the third, prospective part of the study, the efficacy of therapy according to modified international protocols was established in 201 patients, and the results were compared to the ones obtained by therapy according to original international protocols. The efficacy of the treatment was estimated by body temperature measurements and laboratory parameters (leukocytes, C-reactive protein, fibrinogen, erythrocyte sedimentation rate and procalcitonin) on day 1 and day 7 of hospitalization. The scoring system for body temperature and laboratory parameters was designed to compare therapeutic regimes efficiency. For statistical analysis, we used a software package Statistical Package for Social Sciences- SPSS 21. The values of p<0.05were considered statistically significant. Results.Monitoring of antibiotic resistance patterns in our community led to modification international protocols for treating infections caused by E. coli and S aureus. Resistance of E.coli to ciprofloxacin (recommended for the treatment of urinary tract infectionsby international protocols) from urine culture in 2012 and 2013 was 38.8% and 57.1% respectively, while resistance to levofloxacin in 2012 and 2013 was 27.7% and 28.6%, respectively. Resistance of S. aureus to cefazolin (recommended by international protocols for the treatment of the skin and soft tissue infections) from wound cultures in 2012 and 2013 was 25% while the resistance to clindamycin was not present. Resistance to cefazolin (recommended for the treatment of bacterial tonsillopharyngitisby international protocols) from throat culture in 2012 and 2013 was 18,1% and 14,2%, respectively,and the resistance to clindamycin was not present in the same period. Accordingly, clinical therapeutic protocols were modified, levofloxacin was recommended for urinary tract infections and clindamycin was recommended for treatment of tonsillopharyngitis and skin and soft tissues infections caused by S. aureus. Comparing the total score of clinical and laboratory parameters, the treatment of patients according to the adopted international protocols was statistically significantly more effective compared to the one based on clinical experience of physicianin urinary tract infections (p = 0.034) and skin and soft tissue infections(p = 0.032). No statically significant difference (p>0.05) was observed in efficiency of treatment options for other studied bacterial infections. In therapy of urinary tract infections, modified international protocols proved to be significantly more efficient than the adopted international protocols (p = 0.025) when the total score of clinical and laboratory parameters was compared. Comparing the total score of clinical and laboratory parameters, both adopted international protocols and modified international protocols proved to be equally efficient (p=0,100) in therapy of bacterial tonsillopharyngitis and skin and soft tissue infections. Conclusion:Comparison of the obtained results made possible to develop the optimal way of treating diseases of bacterial etiology, taking into account recommendations by international guidelines.The results suggest that the monitoring of the local structure of pathogens and their resistance pattern enabled the determination of optimal treatment options for urinary tract infections and skin and soft tissue infections, respecting international recommendations and modifying the international guidelines to match bacterial resistance pattern in our community.</p>
| Identifer | oai:union.ndltd.org:uns.ac.rs/oai:CRISUNS:(BISIS)100308 |
| Date | 11 July 2016 |
| Creators | Petrić Vedrana |
| Contributors | Stefan-Mikić Sandra, Brkić Snežana, Medić Deana, Sević Siniša, Turkulov Vesna, Vrbić Miodrag |
| Publisher | Univerzitet u Novom Sadu, Medicinski fakultet u Novom Sadu, University of Novi Sad, Faculty of Medicine at Novi Sad |
| Source Sets | University of Novi Sad |
| Language | Serbian |
| Detected Language | Unknown |
| Type | PhD thesis |
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