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系統識別號 U0026-0812200914075730
論文名稱(中文) 淋病雙球菌感染的臨床處置與大環內酯類藥物抗藥性基因分析
論文名稱(英文) Clinical Management for Gonorrhea and Gene Analysis of Macrolide Resistance in Neisseria Gonorrhoeae.
校院名稱 成功大學
系所名稱(中) 臨床醫學研究所
系所名稱(英) Institute of Clinical Medicine
學年度 96
學期 1
出版年 97
研究生(中文) 陳柏齡
研究生(英文) Po-Lin Chen
電子信箱 cplin@mail.ncku.edu.tw
學號 cplin
學位類別 碩士
語文別 中文
論文頁數 52頁
口試委員 指導教授-柯文謙
口試委員-林秋烽
口試委員-陳國東
口試委員-顏經洲
中文關鍵字 抗生素治療  抗藥性  淋病  大環內酯類藥物抗藥性基因  淋病雙球菌 
英文關鍵字 gene for macrolide resistance  gonorrhea  antimicrobial therapy  drug resistance  Neisseria gonorrhoeae 
學科別分類
中文摘要 第一部
淋病的抗生素治療與處置:在高度抗藥性菌株盛行地區所作的調查
摘要
研究背景
台灣Neisseria. gonorrhoeae菌株抗藥性嚴重,因此,正確地選擇合適的抗生素來治療N. gonorrhoeae感染,對於淋病的治療與控制是一個很重要的議題。
材料與方法
在1999至2004年期間,南部一家醫學中心內所有臨床Neisseria gonorrhoeae菌株都保存於臨床微生物實驗室。總計有65株分離自不同病人的臨床菌株被保留下來,這些菌株經再培養仍然存活,可供後續的測試,我們回顧這65名淋病病人的資料,並進一步地加以分析。經再培養後的菌株進行Etest抗微生物製劑藥物敏感性試驗,測試的結果部份已發表在研究生林家偉的碩士論文中(1),並以測試的結果評估當初是否使用了合適的抗生素。
結果
尿道炎是男性病人最常見的臨床表現,佔所有男性病人的89%;女性病人最常見的是骨盆腔發炎性疾病,佔所有女性病人的42%。平均而言,病人需要針對同一次的淋病接受超過2次以上的抗生素治療和3次以上的追蹤。有46%的病人同時接受其他性病的檢查,64%的淋病病人被通報至公共衛生部門。所有的病人至少針對淋病接受一次以上的抗生素治療,更進一步分析,在第一次求診就接受有效抗生素的病人只佔所有病人的6.5%,第二次和第三次則分別有38.8%和37%接受有效的抗生素治療。抗生素當中最常使用的是tetracycline,佔30.6%,第二位是cefuroxime,佔16.8%,第三位是fluoroquinolone類藥物(包含lomefloxacin, ofloxacin和levofloxacin),共佔15.3%。
結論
淋病的抗生素治療及處置仍然有很大的改善空間,同時也必須加強臨床醫師對於性病處理的教育訓練,依據臨床菌株的藥物敏感性試驗結果,第三代頭孢菌素和spectinomycin為目前建議的淋病治療用藥。
第二部
淋病雙球菌大環內酯類藥物抗藥性基因分析:erm基因和mtrR突變的篩檢
摘要
研究背景
之前的研究顯示,台南地區N. gonorrhoeae對於紅黴素(erythromycin)和阿齊黴素(azithromycin)的敏感性降低,本實驗探臨床N. gonorrhoeae菌株多種不同大環內酯類(macrolide)藥物抗藥性機轉。
材料與方法
在1999至2004年間,共計有48株N. gonorrhoeae菌株可供分析。這48株菌株以PCR的方式檢驗是否具有抗藥性基因: erm(A), erm(B), erm(C), erm(F)及mef(A)。並以PCR和定序的方式檢查mtrR驅動區域是否有突變。
結果
在48株菌株當中,31株(64.6%)具有紅黴素(erythromycin)中等程度抗藥性(MIC > 1 mg/L)。其中45株(93.7%)在mtrR驅動區具有相同的adenine缺失突變。在這 45株菌株中,12株具有erm(B)基因,1株具有erm(A)基因。所有菌株經檢驗後都沒有帶mef(A)、erm(C)和erm(F)基因。在17株erythromycin MIC >1 mg/L的菌株當中,有2株並無檢查到突變或帶抗藥性基因,20株單具mtrR的突變,另9株同時具有mtrR突變和攜有erm(B)基因。同時具有mtrR突變和erm抗藥性基因並不會造成紅黴素MIC的特別增加。以單株抗體加上隨意引子聚合鏈反應(arbitrarily-primed PCR, AP-PCR)是一種有效的鑑別方式,可以區分菌株群中的關係,本實驗檢驗的N. gonorrhoeae菌株中,並無主要的同源菌株存在。
結論
在台南地區分離出的N. gonorrhoeae具有很高的mtrR突變盛行率,這樣的突變可能會造成macrolide類藥物的抗藥性。因此,根據過去文獻上報導的治療失敗經驗和可能浮現的抗藥性,以azithromycin治療淋病時必須非常小心。
英文摘要 Part I.
Antimicrobial Therapy and Management for Gonorrhea in an Area with High-Level Antibiotic Resistance
Abstract
Background The choice of antimicrobial agents for gonorrhea is an important issue of public health in an area where the prevalence of drug resistance is high.
Methods During 1999 to 2004, all Neisseria gonorrhoeae isolates causing clinical gonococcal disease were collected in the National Cheng Kung University Hospital. All stored isolates were subcultured in clinical microbiology laboratory and total 65 N. gonorrhoeae isolates were available. In vitro susceptibility tests of seven antimicrobial agents for available strains by Etest strips were performed and results were demonstrated in the previous study (1). Therein, we retrospectively reviewed and analyzed antimicrobial therapy of the 65 infected persons.
Results Urethritis (89%) and pelvic inflammatory diseases (42%) were the most common presentation among males and females, respectively. In average, these patients needs more than 2 courses of antimicrobial therapy, and 3 visits for index infections in outpatient clinics. Clinical surveys of other sexually-transmitted diseases (STDs) were seen in 46% of patients, and 64% were reported to public health department by doctors. All isolates were not susceptible to penicillin, and tetracycline resistance rate was nearly 100%. Among patients receiving antibiotic treatment, 6.5%, 38.8% and 37% of them had in vitro active agents in the visit 1, 2, 3 respectively. Antimicrobial agents prescribed for gonococcal infections were tetracycline (30.6%), followed by cefuroxime (16.8%) and fluoroquinolones (including ciprofloxacin, lomefloxacin, ofloxacin and levofloxacin; 15.3%).
Conclusions There is a lot of space for doctors to improve antibiotic treatment and management for gonorrhea. It is crucial to develop treatment guidelines according to regional antimicrobial resistances and educational programs to improve clinical care of STDs. According to drug susceptibility test, recommended antibiotics for gonorrhea include third-generation cephalosporin and spectinomycin.
Part II.
Screening of erm genes and mtrR mutations in Neisseria gonorrhoeae isolates with decreased macrolide susceptibility
Abstract
Background In a previous study in southern Taiwan, decreased erythromycin and azithromycin susceptibilities of N. gonorrhoeae were noted. Therefore, this study was undertaken to investigate the presence of various macrolide-resistant genes and mutation in N. gonorrhoeae isolates.
Materials and methods Total 48 N. gonorrhoeae isolates collected during 1999 and 2004 were available for analysis. All isolates were examined the presence of erm(B), erm(C), erm(F), mef(A) genes by PCR amplification. Mutation in mtrR region was screened with PCR amplification and sequencing.
Results Of the 48 clinical isolates, 31 (64.6%) were erythromycin intermediate resistance (MIC>1 mg/L). Forty-five (93.7%) isolates had the common adenine deletion in the mtrR promoter region. Among the 45 isolates, 12 were positive for erm(B) gene and 1 positive for erm(A) gene. No isolates possessed mef(A), erm(C), and erm(F) genes. Among 17 isolates with erythromycin MIC < 1.0 mg/L, 12 had mtrR mutation, 3 had concurrent mtrR mutation and erm(B) gene, and one carried erm(B) gene only. Of the 31 isolates with erythromycin MIC > 1.0 mg/L, two had no mutation or acquired resistant genes, 20 possessed only mtrR mutation, and the other 9 had concurrent mtrR mutation and ermB gene. Isolates with mtrR mutation and erm genes did not have higher erythromycin MIC level than those with only mtrR mutation. Serotyping with monoclonal antibody plus arbitrarily-primed PCR (AP-PCR) was a powerful tool to clarify the relationship among bacterial isolates. In the present study, there was no predominate clone among the N. gonorrhoeae isolates.
Conclusion High prevalence of mtrR mutations was noted in N. gonorrhoeae isolates in southern Taiwan. Treatment with azithromycin for gonococcal infection should be careful due to previous treatment failure report and potential emergence of drug resistance.
論文目次 中文摘要 (淋病的抗生素治療與處置:在高度抗藥性菌株盛行地區所作的調查) P.1
Abstract (Antimicrobial Therapy and Management for Gonorrhea in an Area with High-Level Antibiotic Resistance) P.3
第一部 淋病的抗生素治療與處置:在高度抗藥性菌株盛行地區所作的調查 P.5
第一章 研究背景 P.5
第二章 研究對象 P.6
第三章 材料和方法 P.7
第四章 結果 P.7
第一節淋病病人的臨床表現 P.7
第二節 對於淋病不恰當的抗生素治療 P.7
第三節 淋病個案通報和性病篩檢 P.9
第四節 藥物敏感性試驗 P.9
第五章 討論 P.10
第六章 結論 P.13
中文摘要 (淋病雙球菌大環內酯類藥物抗藥性基因分析:erm基因和mtrR突變的篩檢) P.14
Abstract (Screening of erm genes and mtrR mutations in Neisseria gonorrhoeae isolates with decreased macrolide susceptibility) P.16
第二部 淋病雙球菌感染的臨床處置與大環內酯類藥物抗藥性基因分析 P.18
第一章 研究背景 P.18
第二章 材料和方法 P.20
第一節 血清群和血清變異型的區分 P.20
第二節分子生物學鑑定法: 隨意引子聚合鏈反應 arbitrarily primed PCR (AP-PCR) P.20
第三節 利用PCR方式偵測macrolide的抗藥性基因 P.21
第四節 mtrR基因的分析 P.21
第三章 結果 P.22
第一節 Macrolide MIC 和抗藥性基因關聯 P.22
第二節 利用AP-PCR和血清抗體鑑別菌株親緣 P.23
第四章 討論 P.23
第五章 結論 P.23
參考文獻 P.27
附錄 P.48
自述 P.53
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