MURAT TELLİ, Mete EYİGÖR, Yasin TİRYAKİ, NERİMAN AYDIN

Streptococcus pyogenes suşlarında makrolid direnç mekanizmaları ve oranları (Aydın)

Streptococcus pyogenes bakteriyel farenjitin en sık nedenidir. Makrolidler, beta-laktam alerjisi olanlarda ve penisilinle tedavide başarısız olanlarda sıklıkla penisilin yerine önerilmektedir. Çalışmamızda, Streptococcus pyogenes izolatlarında, makrolid direnç oranlarını ve direnç mekanizmalarını belirlemek amaçlanmıştır. Ocak 2007 ve Mayıs 2010 tarihleri arasında çeşitli klinik örneklerden (59 boğaz, 19 yara, 3 kan ve 4 diğer) toplam 85 S.pyogenes suşu elde edilmiştir. Suşların eritromisin, klindamisin, penisiline minimal inhibitör konsantrasyonları mikrodilüsyon yöntemi ile, tetrasiklin, vankomisin, seftriakson, levofloksasine duyarlılıkları disk difüzyon yöntemi ile CLSI kurallarına göre test edilmiştir. Makrolid direnç fenotipleri için çift disk testi uygulanmıştır. Makrolid direnç genleri ise (ermA, ermB, ermC, ermTR ve mefA) polimeraz zincir reaksiyonu ile araştırılmıştır. Eritromisin, tetrasiklin ve levofloksasine direnç sırasıyla % 15, % 19, % 1 oranında bulunmuştur. Eritromisine dirençli suşlardan 7 (% 54) tanesi $iMLS_{B}$, 6 (% 46) tanesi M (efluks) fenotipinde bulunmuştur. $iMLS_{B}$ fenotipindeki suşların hepsinde ermTR direnç geni, M fenotipindeki suşların hepsinde ise mefA direnç geni bulunmuştur. Test ettiğimiz S.pyogenes suşlarında makrolidlere direnç oranı ve $iMLS_{B}$ direnç mekanizması ülkemizden bildirilen önceki oranlara göre yüksek bulunmuştur. Çalışmamız sonucunda makrolid dirençli S.pyogenes suşlarının takibinin yapılması ve epidemiyolojik verilerinin oluşturulması gerekliliği düşünülmüştür.

Macrolide resistance mechanism and ratio in streptococcus pyogenes strains in Aydın, Turkey

Streptococcus pyogenes is the most common cause of bacterial pharyngitis. Macrolides are often recommended substitutes for patients hypersensitive to beta-lactam antibiotics and in whom therapy with these drugs fails. The aim of this study was to detect macrolide resistance types and their respective ratios in clinical isolates of S.pyogenes. Between January 2007 and May 2010, 85 S.pyogenes isolates were obtained from samples of the throat (n=59), wounds (n=19), blood (n=3), and other sites (n=5) of patients. The minimum inhibitory concentrations (MICs) of erythromycin, clindamycin and penicillin against the isolates were determined by the microdilution method. The susceptibility of the isolates to tetracycline, vancomycin, ceftriaxone and levofloxacin was tested by the disc diffusion method. All susceptibility tests were performed and interpreted according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Macrolide resistance phenotypes were identified in a double-disc test, and macrolide resistance genes (ermA, ermB, ermC, ermTR ve mefA) were investigated by polymerase chain reaction (PCR). Strains resistant to erythromycin, tetracycline and levofloxacin accounted for 15 %, 19 % and 1 % of the isolates, respectively. Among erythromycin-resistant S.pyogenes strains, 7 (54 %) were of the $iMLS_{B}$ phenotype and 6 (46 %) were of the M (efflux) phenotype. All $iMLS_{B}$ phenotype strains carried the ermTR resistance gene and all M phenotype strains carried the mefA gene. Our erythromycin resistance and $iMLS_{B}$ resistance mechanism rates were higher compared to other reports in Turkey. Thus, continuous monitoring of macrolide-resistant S.pyogenes strains is needed as the basis for epidemiological studies.

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1. Acikgoz ZC, Gocer S, Tuncer S. Macrolide resistance determinants of group A streptococci in Ankara, Turkey, J Antimicrob Chemother 2003; 52(1):110-2. http://dx.doi.org/10.1093/jac/dkg300 PMid:12805256
2. Akata F, Oztürk D, Tansel O et al. Resistance to macrolides in Group A streptococci from the European section of Turkey: genetic and phenotypic characterization, Int J Antimicrob Agents 2002; 20(6):461-3. http://dx.doi.org/10.1016/S0924-8579(02)00241-8
3. Ardanuy C, Domenech A, Rolo D et al. Molecular characterization of macrolide- and multidrug-resistant Streptococcus pyogenes isolated from adult patients in Barcelona, Spain (1993-2008), J Antimicrob Chemother 2010;65(4):634-43. http://dx.doi.org/10.1093/jac/dkq006 PMid:20118164
4. Bae SY, Kim JS, Kwon JA et al. Phenotypes and genotypes of macrolide-resistant Streptococcus pyogenes isolated in Seoul, Korea, J Med Microbiol 2007;56(Pt 2):229-35. http://dx.doi.org/10.1099/jmm.0.46825-0 PMid:17244805
5. Bayraktar B, Başarı F, Bulut E. A grubu beta-hemolitik streptokoklarda antibiyotik duyarlılık ve makrolid direnç fenotipi, ANKEM Derg 2008;22(3):127-31.
6. Billal DS, Hotomi M, Yamauchi K et al. Macrolide-resistant genes of Streptococcus pyogenes isolated from the upper respiratory tract by polymerase chain reaction, J Infect Chemother 2004;10(2):115-20. http://dx.doi.org/10.1007/s10156-004-0302-x PMid:15160306
7. Bingen E, Bidet P, Mihaila-Amrouche L et al. Emergence of macrolide-resistant Streptococcus pyogenes strains in French children, Antimicrob Agents Chemother 2004;48(9):3559-62. http://dx.doi.org/10.1128/AAC.48.9.3559-3562.2004 PMid:15328126 PMCid:514735
8. Binso AL, Stevens DL. Streptococcus pyogenes, Mandell GL, Bennett JE, Dolin R (eds). Mandell, Douglas and Bennetts Principles and Practice of Infectious Diseases, 6th ed kitabında s.2362-79, Churchill Livingstone, Philadelphia (2005).
9. Bley C, van der Linden M, Reinert RR. mef(A) is the predominant macrolide resistance determinant in Streptococcus pneumoniae and Strepto-coccus pyogenes in Germany, Int J Antimicrob Agents 2011;37(5):425-31. http://dx.doi.org/10.1016/j.ijantimicag.2011. 01.019 PMid:21419605
10. Calatayud L, Ardanuy C, Cercenado E et al. Serotypes, clones, and mechanisms of resistance of erythromycin-resistant Streptococcus pneumoniae isolates collected in Spain, Antimicrob Agents Chemother 2007;51(9):3240-6. http://dx.doi.org/10.1128/AAC.00157-07 PMid:17606677 PMCid:2043242
11. Clinical and Laboratory Standards Institute. Methods for dilution antimicrobial susceptibility test for bacteria that grow aerobically, 7th ed., Approved standard M7A6, Clinical and Labo-ratory Standards Institute, Wayne, PA (2006).
12. Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; 17th informational supplement, CLSI document M100-S17, Clinical and Laboratory Standards Institute, Wayne, PA (2007).
13. Colakoglu S, Alacam R, Hascelik G. Prevalence and mechanisms of macrolide resistance in Streptococcus pyogenes in Ankara, Turkey, Scand J Infect Dis 2006;38(6-7):456-9. http://dx.doi.org/10.1080/00365540500546290 PMid:16798693
14. Creti R, Gherardi G, Imperi M et al. Association of group A streptococcal emm types with virulence traits and macrolide-resistance genes is independent of the source of isolation, J Med Microbiol 2005;54(10):913-7. http://dx.doi.org/10.1099/jmm.0.46035-0 PMid:16157543
15. De Azavedo JC, Yeung RH, Bast DJ, Duncan CL, Borgia SB, Low DE. Prevalence and mechanisms of macrolide resistance in clinical isolates of group A streptococci from Ontario, Canada, Antimicrob Agents Chemother 1999;43(9):2144-7. PMid:10471555 PMCid:89437
16. Descheemaeker P, Chapelle S, Lammens C et al. Macrolide resistance and erythromycin resistance determinants among Belgian Streptococcus pyogenes and Streptococcus pneumoniae isolates, J Antimicrob Chemother 2000;45(2):167-73. http://dx.doi.org/10.1093/jac/45.2.167 PMid:10660498
17. Desjardins M, Delgaty KL, Ramotar K, Seetaram C, Toye B. Prevalence and mechanisms of eryth-romycin resistance in group A and group B Streptococcus: implications for reporting susceptibility results, J Clin Microbiol 2004;42(12):5620-3. http://dx.doi.org/10.1128/JCM.42.12.5620-5623.2004 PMid:15583291 PMCid:535282
18. Dundar D, Sayan M, Tamer GS. Macrolide and tetracycline resistance and emm type distribution of Streptococcus pyogenes isolates recovered from Turkish patients, Microb Drug Resist 2010; 16(4):279-84. http://dx.doi.org/10.1089/mdr.2010.0021 PMid:20624096 PMCid:3124751
19. Farrell DJ, Morrissey I, Bakker S, Felmingham D. Detection of macrolide resistance mechanisms in Streptococcus pneumoniae and Streptococcus pyogenes using a multiplex rapid cycle PCR with microwell-format probe hybridization, J Antimicrob Chemother 2001;48(4):541-4. http://dx.doi.org/10.1093/jac/48.4.541 PMid:11581234
20. Green MD, Beall B, Marcon MJ et al. Multicentre surveillance of the prevalence and molecular epidemiology of macrolide resistance among pharyn-geal isolates of group A streptococci in the USA, J Antimicrob Chemother 2006;57(6):1240-3. http://dx.doi.org/10.1093/jac/dkl101 PMid:16556634
21. Kataja J, Huovinen P, Skurnik M, Seppälä H and The Finnish Study Group for Antimicrobial Resistance. Erythromycin resistance genes in group A streptococci in Finland, Antimicrob Agents Chemother 1999;43(1):48-52. PMid:9869564 PMCid:89019
22. Klugman, KP, Capper T, Widdowson CA, Koornhof HJ, Moser W. Increased activity of 16-membered lactone ring macrolides against erythromycin-resistant Streptococcus pyogenes and Streptococcus pneumoniae: characterization of South African isolates, J Antimicrob Chemother 1998;42(6):729-34. http://dx.doi.org/10.1093/jac/42.6.729 PMid:10052895
23. Liang Y, Shen X, Huang G, Wang C, Shen Y, Yang Y. Characteristics of Streptococcus pyogenes strains isolated from Chinese children with scarlet fever, Acta Paediatr 2008;97(12):1681-5. http://dx.doi.org/10.1111/j.1651-2227.2008.00983.x PMid:18691162
24. Liu X, Shen X, Chang H et al. High macrolide resistance in Streptococcus pyogenes strains isolated from children with pharyngitis in China, Pediatr Pulmonol 2009;44(5):436-41. http://dx.doi.org/10.1002/ppul.20976 PMid:19360846
25. Luca-Harari B, Ekelund K, van der Linden M, Staum-Kaltoft M, Hammerum AM, Jasir A. Clinical and epidemiological aspects of invasive Streptococcus pyogenes infections in Denmark during 2003 and 2004, J Clin Microbiol 2008; 46(1):79-86. http://dx.doi.org/10.1128/JCM.01626-07 PMid:17959766 PMCid:2224248
26. Michos AG, Bakoula CG, Braoudaki M et al. Macrolide resistance in Streptococcus pyogenes: prevalence, resistance determinants, and emm types, Diagn Microbiol Infect Dis 2009;64(3):295-9. http://dx.doi.org/10.1016/j.diagmicrobio.2009. 03.004 PMid:19395219
27. Nir-Paz R, Block C, Shasha D et al. Macrolide, lincosamide and tetracycline susceptibility and emm characterisation of invasive Streptococcus pyogenes isolates in Israel, Int J Antimicrob Agents 2006;28(4):313-9. http://dx.doi.org/10.1016/j.ijantimicag.2006.07.005 PMid:16973336
28. Pérez-Trallero E, Montes M, Orden B, Tamayo E, García-Arenzana JM, Marimón JM. Phenotypic and genotypic characterization of Streptococcus pyogenes isolates displaying the MLSB phenotype of macrolide resistance in Spain, 1999 to 2005, Antimicrob Agents Chemother 2007;51(4):1228-33. http://dx.doi.org/10.1128/AAC.01054-06 PMid:17242142 PMCid:1855467
29. Reinert RR, Lütticken R, Sutcliffe JA et al. Clonal relatedness of erythromycin-resistant Strepto-coccus pyogenes isolates in Germany, Antimicrob Agents Chemother 2004;48(4):1369-73. http://dx.doi.org/10.1128/AAC.48.4.1369-1373.2004 PMid:15047546 PMCid:375310
30. Seppälä H, Skurnik M, Soini H, Roberts MC, Huovinen P. A novel erythromycin resistance methylase gene (ermTR) in Streptococcus pyogenes, Antimicrob Agents Chemother 1998;42(2):257-62. PMid:9527769 PMCid:105397
31. Silva-Costa C, Pinto FR, Ramirez M, Melo-Cristino J and Portuguese Surveillance Group for the Study of Respiratory Pathogens. Decrease in macrolide resistance and clonal instability among Streptococcus pyogenes in Portugal, Clin Microbiol Infect 2008;14(12):1152-9. http://dx.doi.org/10.1111/j.1469-0691.2008.02104.x PMid:19046174
32. Silva-Costa C, Ramirez M, Melo-Cristino J. Identification of macrolide-resistant clones of Streptococcus pyogenes in Portugal, Clin Microbiol Infect 2006;12(6):513-8. http://dx.doi.org/10.1111/j.1469-0691.2006.01408.x PMid:16700698
33. Sutcliffe J, Grebe T, Tait-Kamradt A, Wondrack L. Detection of erythromycin-resistant determinants by PCR, Antimicrob Agents Chemother 1996; 40(11):2562-6. PMid:8913465 PMCid:163576
34. Sutcliffe J, Tait-Kamradt A, Wondrack L. Streptococcus pneumoniae and Streptococcus pyogenes resistant to macrolides but sensitive to clindamycin: a common resistance pattern mediated by an efflux system, Antimicrob Agents Chemother 1996;40(8):1817-24. PMid:8843287 PMCid:163423
35. Szczypa K, Sadowy E, Izdebski R, Hryniewicz W. A rapid increase in macrolide resistance in Streptococcus pyogenes isolated in Poland during 1996-2002, J Antimicrob Chemother 2004;54(4):828-31. http://dx.doi.org/10.1093/jac/dkh420 PMid:15329367
36. Uh Y, Jang IH, Hwang GY, Lee MK, Yoon KJ, Kim HY. Antimicrobial susceptibility patterns and macrolide resistance genes of beta-hemolytic streptococci in Korea, Antimicrob Agents Chemother 2004;48(7):2716-8. http://dx.doi.org/10.1128/AAC.48.7.2716-2718.2004 PMid:15215133 PMCid:434227