임상미생물검사 신빙도 조사 결과보고(2000)

임상미생물검사 신빙도 조사 결과보고 (2000)

대한임상검사정도관리협회 임상미생물분과위원회대한임상검사정도관리협회 임상미생물분과위원회

김의종김의종 (( 집필대표집필대표 ), ), 강정옥강정옥 , , 김미나김미나 , , 김민중김민중 , , 김성일김성일 , , 이경원이경원 , , 이도현이도현 , , 이장호이장호 , , 이남용이남용 , , 이창규이창규 , , 신종희신종희 , ,

장철훈장철훈 , , 최혜심최혜심

Table 1. Microorganisms distributed for External Quality Assessment of Clinical Microbiology Laboratory in 2000

Trial Specimen

number

Microorganism Source

I

II

MB0001MB0002MB0003MB0004MB0005

MB0006MB0007MB0008MB0009MB0010

Klebsiella oxytocaEnterococcus faecalisSalmonella spp. Group DProteus vulgarisStaphylococcus aureus

Clinical isolateATCC 29212Clinical isolateATCC 49132ATCC 25923

Staphylococcus aureusEnterococcus faecalisE. coliPseudomonas aeruginosaKlebsiella pneumoniae

ATCC 25923ATCC 29212ATCC 25922ATCC 27853ATCC 700603

Table 2. Performance on the identification of microorganisms distributed for External Quality Assessment of Clinical Microbiology Laboratory in 2000

Specimen Number

No. of laboratories

No. of laboratories indicatedlevel of performance

Good Acceptable

Not acceptable

MB0001MB0002MB0003MB0004MB0005

MB0006MB0007MB0008MB0009MB0010

Klebsiella oxytocaEnterococcus faecalisSalmonella spp. Group DProteus vulgarisStaphylococcus aureus

Staphylococcus aureusEnterococcus faecalisE. coliPseudomonas aeruginosaKlebsiella pneumoniae

217217217217217

225225225225225

209154151209213

217175223213222

-40471-

-35-91

8231974

815232

Microorganisms

Not acceptable for the identification

Enterococcus faecalisEnterococcus faecalisMB0002 10.6% (23/217) MB0002 10.6% (23/217) MB0007 6.7% (15/225)MB0007 6.7% (15/225)

Salmonella Salmonella spp. Group D spp. Group D

8.8% (19/217)8.8% (19/217)

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-naphthylamide

Group D streptococci: S. bovis, S. equinus

Enterococcus spp.

Motility Yellow colony

E. faecalis - -

E. faecium - -

E. gallinarum + -

E. casseliflavus + +

TSI LIA

Salmonella spp.

TSI agar: K/Ag+, K/Ag-

Lysine iron agar: K/K+

MacConkey agar

SS agar

XLD agar

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

Specimennumber

Microorganisms and antibiotics

No. oflab Good

Not Acceptable

less thanlower limit

more thanupper limit

MB0001 K. oxytoca Cephalothin 153 145(94.8%) NA* 8(5.2%) Cefotaxime 146 94(64.4%) 52(35.6%) NAMB0002 E. faecalis

Ampicillin 170 165(97.1%) 5(2.9%)NA

Vancomycin 170 105(61.8%) 65(38.2%)

NAMB0003 Salmonella Group D

Ampicillin 170 168(98.8%) 2(1.2%)NA

SXT 131 131(100%) 0NAMB0004 P. vulgaris

Cephalothin 154 93(60.4%) NA 61(39.6%)

Gentamicin 174 172(98.8%) 2(1.2%)NA

*NA: not applicable

Salmonella, Shigella

항생제 감수성 검사항생제 감수성 검사AmpicillinAmpicillinCiprofloxacinCiprofloxacinTrimethoprim/sulfamethoxazoleTrimethoprim/sulfamethoxazole

11 세대세대 , 2, 2 세대 세팔로스포린은 검사하지 세대 세팔로스포린은 검사하지 않는다않는다 ..

장외에서 분리된 장외에서 분리된 SalmonellaSalmonellaChloramphenicol, cefotaxime Chloramphenicol, cefotaxime 추가추가

Salmonella, Shigella 33 세대 세팔로스포린 세대 세팔로스포린 ((ceftriaxone, cefotaxime, ceftriaxone, cefotaxime,

cefoperazone cefoperazone 등등 )) 에서 중간 에서 중간 ((intermediate) intermediate) 또는 또는 내성으로 나오면내성으로 나오면 , , ESBL testESBL test 를 실시한다를 실시한다 ..

ESBL: Extended-spectrum ESBL: Extended-spectrum -lactamase-lactamase거의 모든 세팔로스포린으로 치료되지 않는다거의 모든 세팔로스포린으로 치료되지 않는다 ..검사에서 감수성으로 나와도 내성으로 보고한다검사에서 감수성으로 나와도 내성으로 보고한다 ..

ESBL-Shigella: ESBL-Shigella: 세계 최초로 출현세계 최초로 출현 !!!!!!!!!!!! ESBL-Salmonella: ESBL-Salmonella: 간혹 분리되고 있음간혹 분리되고 있음

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

Specimennumber

Microorganisms and antibiotics

No. oflab Good

Not Acceptable

less thanlower limit

more thanupper limit

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

0

10

20

30

40

50

60

6 8 10 12 14 16 18 20 22 24 26

MB0005MB0006

S. aureus (ATCC 25923), Vancomycin

Unacceptable: MB0005 - 38.3% (67/175)

MB0006 - 28.7% (51/178)

Staphylococcus spp. 에서 vancomycin disk

15 mm 이상이어야 감수성으로 판정하고 ,

14 mm 이하이면 반드시 최소억제농도를 측정하여

4 g/mL 이하이면 감수성이며 ,

4 g/mL 보다 크면 내성을 의심해야 한다 .

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

Specimennumber

Microorganisms and antibiotics

No. oflab Good

Not Acceptable

less thanlower limit

more thanupper limit

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

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

Specimennumber

Microorganisms and antibiotics

No. oflab Good

Not Acceptable

less thanlower limit

more thanupper limit

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

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

Specimennumber

Microorganisms and antibiotics

No. oflab Good

Not Acceptable

less thanlower limit

more thanupper limit

MB0005 S. aureus Oxacillin 59 59(100%) 0 0 Vancomycin 65 65(100%) 0

0MB0006 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

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

Specimennumber

Microorganisms and antibiotics

No. oflab Good

Not Acceptable

less thanlower limit

more thanupper limit

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

0

10

20

30

40

50

60

6 8 10 12 14 16 18 20 22 24 26

MB0002MB0007

E. faecalis (ATCC 29212), Vancomycin

Unacceptable: MB0002 - 38.2% (65/170)

MB0007 - 32.4% (56/173)

계속하여 vancomycin 억제대를 작게 보고한 기관

S. aureus: 28 기관 ( 미흡 51 기관 중 54.9%)

E. faecalis: 36 기관 ( 미흡 56 기관 중 64.3%)

Both: 27 기관 ( 총 173 기관 중 15.6%)

Vancomycin (30g) 기준 R I SR I S Staphylococcus Staphylococcus spp. spp.

15 (mm)15 (mm)14mm14mm 이하이하 : : MICMIC 를 측정한다를 측정한다 ..

Enterococcus spp. Enterococcus spp.

14 15-16 14 15-16 17 (mm)17 (mm)

NCCLS M100-S10, 2000

Oxacillin (1g) 기준

R I SR I S S. aureusS. aureus 10 11-12 10 11-12 13 (mm)13 (mm)

Coagulase-negative staphylococci Coagulase-negative staphylococci

17 17 18 (mm)18 (mm)

NCCLS M100-S10, 2000

Ampicillin (10g) 기준

R SR S Enterobacteriaceae Enterobacteriaceae 13 13 17 17

(mm)(mm)

Staphylococci Staphylococci 28 28 2929

Enterococci Enterococci 16 16 1717NCCLS M100-S10, 2000

MB0010

Klebsiella pneumoniae ATCC700603

Positive control strain for extended-spectrum -lactamase

Cefotaxime disk 27mm

Ceftazidime disk 22mm

Aztreonam disk 27mm

Cefpodoxime disk 22mm

ESBL-producing E. coli & Klebsiella

Criteria Susceptible ESBL test Criteria Susceptible ESBL test

Cefotaxime Cefotaxime 23 23 27 mm 27 mm Ceftazidime Ceftazidime 18 18 22 22 Aztreonam Aztreonam 22 22 27 27 Cefpodoxime Cefpodoxime 21 21 22 22 Ceftriaxone Ceftriaxone 21 21 25 25

NCCLS M2-A7, 2000

Double disk synergy test; ESBL

Amoxicillin/Clavulanic acidCefotaxime

Ceftazidime

Aztreonam

Salmonella spp.

Shigella sonnei

Effective -lactams for ESBL

CarbapenemsCarbapenemsImipenem, meropenemImipenem, meropenem

CephamycinsCephamycinsCefotetan, cefoxitin, cefmetazoleCefotetan, cefoxitin, cefmetazole

Anti-Anti-PseudomonasPseudomonas (4 (4 세대세대 ) ) cephalosporinscephalosporinsCefepime, cefpiromeCefepime, cefpirome

-lactamase inhibitor-lactamase inhibitorPiperacillin/tazobactamPiperacillin/tazobactam