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Caract= erización de la infección urinaria adquirida en la comunidad IESS Macas período 2019-2020<= span style=3D'mso-bookmark:_Hlk115294993'>

 

Characterization of the urinary infection acquir= ed in the IESS Macas community period 2019-2020

1

Jhoanna García Mejía                                            https://orcid.org/0000-0003-2344-5= 478

Universidad Cató= lica de Cuenca. Cuenca, Ecuador

jhoanna.garcia.29@est.ucacue.edu.ec

 

2

Carmen = Lucía López Cisneros                          =     https://orcid.org/0000-0002-905= 7-6446

Universidad Católica de Cuenca, Cuenca, Ecuador

carmen.lopez@ucacue.edu.ec

<= /span>

 

 

 

 

 

 

 

 

Artículo de Investigación Científica y Tecnológica<= o:p>

Enviado: 06/08/2022

Revisado: 11/09/2022

Aceptado: 17/10/2022

Publicado: 03/11/2022

DOI: https://doi.org/10.33262/anatomiadigita= l.v5i4.1.2384      

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Cítese: <= o:p>

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García Mejía, J., & López Cisneros, C. L. (2022= ). Caracterización de la infección urinaria adquirida en la comunidad IESS M= acas período 2019-2020. Anatomía Digital, 5(4.1), 63-83. https://doi= .org/10.33262/anatomiadigital.v5i4.1.2384

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Esta revista está protegida bajo una licencia Creative Commons Attribution Non Commercial No Derivatives 4.0 International. Copia de la licencia: http://creativecomm= ons.org/licenses/by-nc-nd/4.0/

 

Palabras claves:

Infección del tracto urinario, Prevalencia, E. coli, Sensibilidad microbiana, Betalactamasa de espectro extendido. <= o:p>

 

 

Resumen=

Introducción. Las Infecciones del Tracto Urinario (ITU), constituyen uno de los principales motivos de consulta en el ámbito de atención primaria, debido al aumento = de la resistencia antibacteriana. Objetivo. Caracterizar la prevalencia de infecciones del tracto urinario y el perfi= l de susceptibilidad antimicrobiana en enterobacterias aisladas de pacientes oriundos de la provincia Morona Santiago – Ecuador. Método. Esta investigación fue descriptiva de diseño documental. La población fue de 1= 488 registros de urocultivos, recopilados de la base de datos del laboratorio= de microbiología del Centro Clínico Quirúrgico Ambulatorio Hospital del Día Macas, en el período comprendido desde enero 2019 hasta diciembre de 2020. Los datos fueron procesados mediante estadística descriptiva, análisis de frecuencia y chi cuadrado. Resultados. La prevalencia de ITU fue 55,6%; los principales agentes etiológicos fueron:= E. coli (88,0%), Klebsiella spp., (7,5%), y Proteus spp. (2,4%). Las ITU y la infección por E. coli fueron estadísticamente mayores en mujeres adultas. La mayor frecuencia de resistencia de E. coli fue para cefazolina (42,4%), sulfametoxazol trimetoprima (40,6%), norfloxacina (38,0%), ácido nalidíxi= co (34,3%) y ciprofloxacina (31,4%) en Klebsiella spp. fue norfloxaci= na (7,5%), cefazolina (7,2%), cefuroxima (4,5%) levofloxacina (3,8%) y ampicilina sulbactam (3,5%). Conclusión. El agente causal más frecuente de las infecciones del tracto urinario contin= úa siendo E. coli. El tratamiento empírico de ITU, a criterio del aut= or debería incluir gentamicina, amikacina y nitrofurantoina.

 

 

Keywords: <= /o:p>

Urinary tract infections, Prevalence,= E. coli; Microbial susceptibility testing, BLEE.<= /o:p>

 

Abstract

Introduction. Urinary Tract Infections (UTI) are one of the main reasons for consultation in the prim= ary care setting, due to the increase in antibacterial resistance. Objetiv= e: To characterize the prevalence of urinary tract infections and the antimicrobial susceptibility profile in enterobacteria isolated from pati= ents from Morona Santiago province - Ecuador. Method: This research was descriptive of documentary design. The population was 1488 records of uri= ne cultures, compiled from the database of the microbiology laboratory of the Hospital del Día Macas Outpatient Surgical Clinical Center, in the period= from January 2019 to December 2020. The data were processed through descriptive statistics, analysis frequency and chi squarE. Results: The prevalence of UTI was 55.6%; the main etiological agents were: E. = coli (88.0%), Klebsiella spp., (7.5%), and Proteus spp. (2.4%). = UTIs and E. coli infection were statistically higher in adult wo= men. The highest frequency of E. coli resistance was for cefazol= in (42.4%), sulfamethoxazole trimethoprim (40.6%), norfloxacin (38.0%), nalidixic acid (34.3%) and ciprofloxacin (31.4 %) in Klebsiella sp= p. was norfloxacin (7.5%), cefazolin (7.2%), cefuroxime (4.5%), levofloxacin (3.8%) and ampicillin sulbactam (3.5%). Conclusion. The causal age= nt and the most frequent of urinary tract infections continues to be E. coli. Empirical treatment of UTI, at the author's discretion, should include gentamicin, amikacin, and nitrofurantoin.

 

 

 

Introducción

La infección del tracto urinario (ITU), se puede definir como un crecimiento exponencial de microorganismos patógenos en una muestra de orina recogida de manera estéril siguiendo los protocolos adecua= dos para su obtención, y que no necesariamente cursa con sintomatología = (1,2). Se conside= ra como una de las patologías más habituales en la comunidad tanto en la atenc= ión primaria como a nivel hospitalario, ocupan el segundo lugar entre los proce= sos infecciosos, siendo la principal causa de bacteriemia y sepsis en adultos mayores (3–5).

Según la Organización Mundial de la Salud (OMS)= por cada 100 habitantes existe una incidencia de 20-30 casos de ITU, lo que representa un alto gasto y un problema en el sistema de salud a nivel mundi= al (6). Cerca de 1= 50 millones de casos de ITU ocurren por año; en Estados Unidos son requeridas 7 millones de consultas médicas ambulatorias cada año a causa de las infeccio= nes del tracto urinario y alrededor de 1 millón de hospitalizaciones, lo que ge= nera un gasto aproximado de 1.6 mil millones de dólares al año (1,7).=

Se considera que las ITU, son enfermedades más frecuentes tanto en el ambiente comunitario como a nivel hospitalario. El Centers for Disease Control and Prevention (CDC) las define como un proceso inflamatorio que implica la invasión y multiplicación de microorganismos en= el tracto urinario (4).=

Las ITU, son causadas generalmente por diversos patógenos que viajan desde la uretra hacia la vejiga, comúnmente en el laboratorio se aíslan con mayor frecuencia bacterias del tipo gram negativas que pertenecen a la familia Enterobacteriaceae (8,9). Alrededor = de un 80-90% de los casos existentes se le atribuye a un solo agente causal re= sponsable de las infecciones del tracto urinario se trata del microorganismo patógeno= Escherichia coli (E. coli), (10–12)= . Existen ot= ros microorganismos que pueden causar infecciones urinarias como Staphylococ= cus saprophyticus, Proteus spp., Klebsiella spp., Enteroba= ter spp., Enterococcus spp., y Pseudomonas aeruginosa (4).

Diversas investigaciones realizadas en Ecuador describen una alta prevalencia de E. coli; en Quito se realiz= ó un estudio en el Hospital de Especialidades Carlos Andrade Marín (HACAM) en el cual las infecciones del tracto urinario eran causadas principalmente por <= i>E. coli con un 48,39%, y en menor incidencia: Klebsiella pneumoniae<= /i> 3,23% y Streptococcus agalactiae 3,23%. En este caso la mayor resist= encia a los antibióticos que tuvo E. coli fue a clotrimoxazol con 2= 2,58%; ciprofloxacino, gentamicina, nitrofurantoína, ampicilina y norfloxacino con= 9,68% (13–15)= .=

En otro estudio realizado en la provincia de Manabí, concuerda que el microrganismo más frecuentemente aislado fue E.= coli con un porcentaje del 78,48%; seguido de Proteus mira= bilis 6,33% y Klebsiella pneumoniae 5,06%. Los mayores porcentajes = de resistencia se observaron para amoxicilina (78,48 %) y cefalexina (71,83 %) alcanzando elevados porcentajes de resistencia para estos antibióticos (16).

En un estudio realizado en el Hospital General = de Ambato, la ITU es más frecuente en mujeres, el signo más importante es el a= lza térmica que se presentó en 160 (68,67%) pacientes. Se identifica a E. coli con un porcentaje de 42,49 %, como el agente etiológico más común en la ITU= y con gran incidencia de resistencia antimicrobiana especialmente BLEE proveniente de la comunidad que constituye un serio problema de salud públi= ca (17).=

Un considerable número de bacterias patógenas de importancia clínica han desarrollado diferentes mecanismos de resistencia. = En este contexto, Escherichia coli se presenta como la más prevalente, misma que fue declarada por la OMS como un patógeno prioritario dentro del campo de investigación para el desarrollo de nuevas alternativas farmacológicas (18,19)= .

Es preocupante la rápida propagación que existe= en el mundo de bacterias multirresistentes, causantes de infecciones que no pu= eden tratarse con una terapia antibiótica común. Diariamente surgen en todo el planeta nuevos mecanismos de resistencia antibacteriana dificultando el adecuado tratamiento, en la Unión Europea se estima alrededor de 25.000 mue= rtes por año a causa de bacterias multirresistentes (20).=

Dentro de los mecanismos de resistencia existen= tes en uropatógenos destaca la presencia de enzimas betalactamasas de espectro extendido (BLEE), las cuales confieren resistencia a varios antibióticos betalactámicos incluido las cefalosporinas de tercera y cuarta generación, = las penicilinas y de conferencia variable a monobactámicos (aztreonam); su acci= ón se impide por inhibidores de β -lactamasas como el ácido clavulánico, ampicilina sulbactam y tazobactam (21).=

Esto conlleva a que exista consecuencias negati= vas que se ven expresadas en términos de morbilidad, mortalidad y gastos sanita= rios derivados de la atención médica que podrían amenazar la sostenibilidad de l= os sistemas de salud (5). Por otro l= ado, la ITU está directamente relacionada al uso de varios antibióticos para pod= er tratar esta patología, pero un tema muy controversial es la resistencia que= se generan a partir de diversos factores tales como: edad, sexo, área geográfi= ca, ente otros (22,23)= .=

Las infecciones del tracto urinario afectan a t= oda la población, generalmente encontrando un predominio más en mujeres que en hombres. Diversas investigaciones consideran que:= 1 de cada 3 mujeres desarrolla una infección urinaria que requiere terapia antimicrobiana antes de los 24 años y, al menos, el 50% una infección del tracto urinario durante el transcurso de su vida con una recurrencia del 40= % (4,24–26).=

El ministerio de salud pública, como ente rector del Sistema Nacional de Salud ha diseñado una guía práctica clínica para el manejo y tratamiento de las infecciones urinarias, en el Ecuador existen protocolos establecidos para tratar y diagnosticar adecuadamente una ITU, s= in embargo en la actualidad se siguen manejando terapias no acordes a las recomendaciones establecidas en la guía clínica (27).=

Según datos obtenidos de la página oficial del = INEC los trastornos del sistema urinario se encuentran dentro de las 10 principa= les causas de morbilidad en el Ecuador, en el año 2019 la infección de las vías genitourinarias en el embarazo es la tercera causa de morbilidad en las muj= eres con 16.010 egresos reportados (28).=

Sin embargo, a pesar de la elevada prevalencia = de ITU, la variedad de factores, los microorganismos asociados y sus impactos negativos sobre los costos a nivel de la salud pública e individual, los estudios sobre esta problemática en Morona Santiago son exiguos.=

La presente investigación resulta novedosa ya q= ue en la provincia de Morona Santiago - Ecuador se desconoce cuál es la prevalencia de infección urinaria adquirida en la comunidad, así como tambi= én el perfil de susceptibilidad antimicrobiana. El principal objetivo de este trabajo fue caracterizar la infección urinaria adquirida en la comunidad y = su respectivo perfil de susceptibilidad antimicrobiana en Enterobacterias segú= n su prevalencia en los pacientes que acuden al IESS Macas en la provincia de Mo= rona Santiago-Ecuador, comprendido en el período enero de 2019 – diciembre de 20= 20.

Metodologia

La presente investigación fue= un estudio cuantitativo, no experimental, descriptivo, transversal de diseño documental. La población de estudio estuvo conformada por 1488 registros en= la base de datos de pacientes que se realizaron urocultivos en el laboratorio = del Centro Clínico Quirúrgico Hospital del Dia Macas, desde enero 2019 hasta diciembre de 2020. Se utilizó un muestreo no probabilístico, de cobertura total, los datos fueron obtenidos de fuentes secundarias ingresados en los registros del departamento de Bacteriología.

Criterios de inclusión: regis= tro de pacientes que se realizaron urocultivos, registro de pacientes que fueron reportados sin crecimiento bacteriano, registro de enterobacterias que al m= enos presentan resistencia a un antibiótico, registro de pacientes de ambos sexo= s.

Criterios de exclusión: regis= tros clínicos que no tengan información completa, registros de urocultivos que fueron reportados como microbiota mixto contaminante, registro de urocultiv= os que sean cocos gram positivos.

El tamaño de la muestra obten= ida fue de 700 registros de pacientes a partir de los criterios de inclusión y exclusión señalados.

Proce= dimiento

Siembra microbiológica: se realizó la siembra bacteriológica de muestras de orina recolectadas del seg= undo chorro, previo el aseo de la zona genital, se sembraron en placas de CLED y= EMB con un asa calibrada de 0,001 ml e incubadas a 37ºC en estufa durante 24 ho= ras (29,30).

Identificación y susceptibili= dad antimicrobiana: la identificación bacteriana se realizó de manera fenotípica mediante la utilización de las siguientes pruebas bioquímicas: urea, sulfuro indol motilidad (SIM), triple azúcar hierro (TSI), descarboxilación de lisina, citrato. En la realización del antibiograma se utilizó una escala de 0,5 de McFarland con los aislados de estudio, la susceptibilidad antimicrobiana se realizó según los lineamentos establecidos por el CLSI 2020 (31).

Test confirmatorio BLEE: se empleó las recomendaciones descritas por el CLSI 2021, obtenida la suspensi= ón bacteriana e inoculada en el agar Mueller – Hinton se procedió a colocar di= scos de susceptibilidad antimicrobiana de ceftazidima (30μg), cefotaxima (30ug), cefepime (30ug), aztreonam (30ug) (centro a centro) y un disco con amoxicilina/ ácido clavulánico. Efecto sinérgico fue interpretado como resultado positivo (21).

Proce= samiento estadístico

Para el análisis estadístico = se generó una base de datos en el programa SPSS 21.0. Los datos fueron procesa= dos mediante estadística descriptiva, análisis de frecuencia y chi cuadrado. Se realizó correlación entre variables, prueba Z de comparación de proporcione= s.

Para la presentación de los resultados se utilizó tablas de simple y doble entrada, tablas cruzadas y l= os gráficos se representaron mediante el empleo de diagrama de barras y diagra= ma de sectores.

Aspectos éticos: esta investigación fue fundamentada en los principios éticos establecidos en la Declaración de Helsinki Adendum de Taiwán 2016 (32,33), se dio protección y privaci= dad a los datos de los pacientes de los cuales se obtuvieron los registros clín= icos objetos de estudio; existió voluntariedad y el consentimiento por parte de = los pacientes para la realización del examen de urocultivo; los datos fueron manejados con estricta confidencialidad; no se vulneró el derecho de ningún= paciente. Se protegió la base de datos con clave de seguridad restringiendo su acceso= ; la información no se utilizó con otros fines que no sean de carácter investigativo, no tuvo manejo público y no se harán nuevas investigaciones, respetando para lo que fueron usadas.

Resultados

En este estudio se evidenció que la frecuencia de las infecciones del tracto urinario fue del 55,6% con respecto al total de urocultivos realizados durante el período de enero 2019 – diciembre 2020 en el Centro Clínico Quirúrgico Ambulatorio Hospital del Dia Macas Morona Santiago- Ecuador.

Según los datos obten= idos se pudo demostrar que las infecciones del tracto urinario se presentan con mayor frecuencia en el género femenino, con una incidencia de 93,1%, seguido del sexo masculino con un de 6,9%. Al evaluar la prevalencia de las infecci= ones del tracto urinario y los uropatógenos en relación con el grupo etario, se identificó que la población adulta es más representativa con un 55,6%, a diferencia de los adultos mayores con un porcentaje de 21,9% a pesar de ser consideraros grupos vulnerables de riesgo.

Los principales agent= es etiológicos fueron E. coli con un valor de 88,0 %, seguido de= Klebsiella spp. con 7,5%, y Proteus spp. con 2,4%. Aunque el porcentaje de P= seudomona aeruginosa sea bajo con 0,4% llama la atención debido a que este uropatógeno se encuentra a nivel intrahospitalario y no en la comunidad. (V= er Gráfico 1).

Figura 1.

Porcentaje de uropatógen= os de infecciones del tracto urinario en pacientes del Centro Clínico Quirúrgi= co Ambulatorio Hospital del Dia Macas Morona Santiago- Ecuador, en el período = de enero 2019 – diciembre 2020

Tabla 1. =

Mecanismo de resistencia BLEE de las infecciones d= el tracto urinario en el Centro Clínico Quirúrgico Ambulatorio Hospital del Di= a Macas. Morona Santiago- Ecuador, en el período de enero 2019 – diciembre 2020.<= o:p>

BLEE * Tab= ulación Cruzada de Especies Bacterianas

 

Especie Bacteriana=

Total

E. coli=

Klebsiella spp=

Proteus spp

Enterobacter spp

Citrobacter freundii

Pseudomoa aeruginosa

 

BLEE

Positivo

Recuento

104a

18b, c<= /span>

2a, c

2a, b, c

2b

0a, b, c

128

% dentro Especie Bacteriana

14,3%

29,0%

10,0%

18,2%

66,7%

0,0%

15,5%

Negativo

Recuento

623a

44b, c<= /span>

18a, c<= /span>

9a, b, c

1b

3a, b, c

698

% dentro Especie Bacteriana

85,7%

71,0%

90,0%

81,8%

33,3%

100,0%

84,5%

Total

Recuento

727

62

20

11

3

3

826

% dentro Especie Bacteriana

100,0%

100,0%

100,0%

100,0%

100,0%

100,0%

100,0%

Nota: IESS Macas período enero2019 – diciembre 2020

La prevalencia de BLEE es del 15,5 %, el uropatógeno con más alto porcentaje en relación con este mecanismo de resistencia es la Citrobacter freundii con 12,6%, siendo esta cifra alarmante en comparación con E. coli= que alcanza un 14.3 % del total de casos positivos (ver tabla 1).

En cuanto, al perfil de susceptibilidad antimicrobiana se consideraron cuatro microorganismos dentro de la población estudiada. Demostrando el mayor porcentaje de resistencia para E. coli<= /i> fue cefazolina 42,4%, sulfametoxazol trimetoprima 40,6%, norfloxacina 38,0%, ácido nalidíxico 34,3%, ciprofloxacina 31,4%.<= /p>

Para Klebsiella spp. no se evidenció una resistencia marcada siendo los porcentajes más altos norfloaxina 7,5%, cefazolina 7,2%, cefuroxima 4,5%, levofloxacina 3,8%, ampicilina sulbactam 3,5%.

Por el contrario, tanto Proteus spp. como Enterobacter spp. presentaron porcentajes inferiores a 1,5% en todas las variables por lo tanto se consid= eran no resistentes. (ver Tabla 2).

Tabla 2. =

Perfil de susceptibilidad antimicrobiana de los principales uropatógenos hallados en las infecciones del tracto urinario en= el Centro Clínico Quirúrgico Ambulatorio Hospital del Dia Macas. Morona Santia= go- Ecuador, en el período de enero 2019 – diciembre 2020.

 

Especie Bacteriana

Escherichia coli

Klebsiella spp.

Proteus spp.

Enterobacter spp.

Antibióticos

GENTAMICINA

R

9.3% (69)

1.7% (13)

0.3% (2)

0.0% (0)

I

3.8% (28)

0.1% (1)

0.0% (0)

0.0% (0)

S

74.6% (554)

6.1% (45)

2.0% (15)

  = 1.3% (10)

AMIKACINA

R

1.7% (11)

0.3% (2)

0.0% (0)

0.0% (0)

I

6.1% (40)

0.2% (1)

0.0% (0)

0.0% (0)

S

79.8% (527)

7.4% (49)

2.3% (15)

  = 1.5% (10)

CIPROFLOXACINA

R

31.4% (234)

3.4% (25)

0.4% (3)

0.5% (4)

I

10.9% (81)

1.7% (13)

0.3% (2)

0.1% (1)

S

45.3% (338)

2.9% (22)

1.5% (11)

0.8% (6)

AMOXICILINA +   ACIDO CLAVULANICO

R

25.8% (206)

3.3% (26)

0.8% (6)

0.5% (4)

I

16.3% (130)

1.0% (8)

0.1% (1)

0.1% (1)

S

46.4% (371)

3.3% (26)

1.4% (11)

0.8% (6)

NITROFURANTOINA

R

2.9% (23)

2.5% (20)

0.7% (6)

0.5% (4)

I

3.5% (28)

1.5% (12)

0.1% (1)

0.1% (1)

S

82.0% (657)

3.5% (28)

1.5 (12)

0.7% (6)

 =

Tabla 2. =

Perfil de susceptibilidad antimicrobiana de los principales uropatógenos hallados en las infecciones del tracto urinario en= el Centro Clínico Quirúrgico Ambulatorio Hospital del Dia Macas. Morona Santia= go- Ecuador, en el período de enero 2019 – diciembre 2020. (continuación)

 

 

 

Especie Bacteriana

 

 

 

Escherichia coli

Klebsiella spp.

Proteus spp.

Enterobacter spp.

TRIMETOPRIMA/   SULF= AMETOXAZOL

R

40.6% (302)

3.4% (25)

0.8% (6)

0.4% (3)

I

0.4% (3)

0.1% (1)

0.0% (0)

0.0% (0)

S

47.1% (350)

4.2% (31)

1.5% (11)

1.1% (8)

CEFTAZIDIMA

R

13.2% (108)

2.3% (19)

0.2% (2)

0.2% (2)

I

0.5% (4)

0.1% (1)

0.1% (1)

0.0% (0)

S

74.2% (608)

5.1% (42)

2.1 (17)

1.1% (9)

CEFEPIME

R

13.6% (111)

2.3% (19)

0.2% (2)

0.2% (2)

I

0.5% (4)

0.4% (3)

0.0% (0)

0.0% (0)

S

73.7% (600)

4.9% (40)

2.2% (18)

1.1% (9)

ÁCIDO NALIDÍXICO

R

34.3% (214)

3.2% (20)

1.1% (7)

0.6% (4)

I

2.9% (18)

1.4% (9)

0.0% (0)

0.0% (0)

S

51.2% (319)

3.0% (19)

1.0% (6)

0.6% (4)

NORFLOXACINA

R

38.0% (131)

7.5% (26)

0.6% (2)

0.3% (1)

I

2.3% (8)

0.3% (1)

0.0% (0)

0.0% (0)

S

44.6% (154)

3.8% (13)

0.6 % (2)

0.9% (3)

LEVOFLOXACINA

R

26.8% (128)

3.8% (18)

0.4% (2)

0.4% (2)

I

1.9% (9)

0.4% (2)

0.0% (0)

0.2% (1)

S

58.5% (279)

4.0% (19)

1.5% (7)

0.8% (4)

CEFTRIAXONA

R

16.6% (105)

3.2% (20)

0.5% (3)

0.3% (2)

I

0.8% (5)

0.0% (0)

0.0% (0)

0.0% (0)

S

70.5% (445)

4.9% (31)

1.6% (10)

0.2% (1)

AMPICILINA/ SULBACTAM

R

27.4% (179)

3.5% (23)

0.6% (4)

0.0% (2)

I

6.0% (39)

0.3% (2)

0.2% (1)

0.0% (0)

S

54.5% (356)

4.3% (28)

1.4% (9)

1.1% (7)

CEFUROXIMA

R

19.3% (95)

4.5% (22)

0.6% (3)

0.6% (3)

I

30.0% (148)

1.8% (9)

0.6% (3)

0.4% (2)

S

37.3% (184)

2.6% (13)

1.2% (6)

0.6% (3)

CEFOTAXIMA

R

17.1% (96)

3.2% (18)

0.5% (3)

0.4% (2)

I

0.5% (3)

0.0% (0)

0.0% (0)

0.0% (0)

S

69.4% (390)

5.3% (30)

1.6% (9)

1.4% (8)

 =

Tabla 2. =

Perfil de susceptibilidad antimicrobiana de los principales uropatógenos hallados en las infecciones del tracto urinario en= el Centro Clínico Quirúrgico Ambulatorio Hospital del Dia Macas. Morona Santia= go- Ecuador, en el período de enero 2019 – diciembre 2020. (continuación)

 

 

 

Especie Bacteriana

 

 

 

Escherichia coli

Klebsiella spp.

Proteus spp.

Enterobacter spp.

CEFAZOLINA

R

42.4% (112)

7.2% (19)

1.5% (4)

0.8% (2)

I

5.7% (15)

0.8% (2)

0.0% (0)

0.0% (0)

S

36.7% (97)

1.9% (5)

0.8% (2)

1.5% (4)

Nota: IESS Macas período enero2019 – diciembre 2020

Discusión

Las ITU son una de las principales enfermedades infecciosas diagnosticadas frecuentemente en la práctica clínica, se consideran como una de las patolo= gías más habituales en la comunidad tanto en atención primaria como a nivel hospitalario.

El presente estudio demostró que la incidencia de ITU se encuentra mayoritariamente en la población de mujeres adultas (30-64 años). Esto coin= cide con lo reportado hasta la actualidad, las infecciones urinarias son unas 50 veces más frecuentes en las mujeres de este grupo etario, lo que concuerda = con la investigación realizada por Wurgaft K., en Chile en la unidad de Nefrolo= gía, en la clínica Las Condes (34).

Existen diversos factores que predisponen esta condición entre los más relevantes se destacan ciertas características anatómicas propias de las mujeres, el inic= io de la actividad sexual, el embarazo, uso de condón o diafragma con espermic= ida, tampón vaginal, terapia antimicrobiana previa (35,36).

De igual manera a lo reportado por Palacios y colaboradores en Azuay- Ecuador = (15), el presente estudio identificó que el agente causal más prevalente de las infecciones d= el tracto urinario fue E. coli demostrando que el 88,0% de los urocultivos presentaron dicho crecimiento bacteriano. Esto es similar a los resultados obtenidos de otros estudios en diferentes países como lo probó Navarete en Perú (2) y Zamora en Colombia (37) lo que pone en evidencia de que este microorganismo (E. coli) presenta una incidencia marcada a nivel mundial siendo este uropatógeno el responsable e= ntre un 80-90 % de los casos de las infecciones del tracto urinario (10).

Los resultados de este estudio sobre Ps= eudomona aeruginosa difiere con los de Guevara (38). Esta discrepancia podría atribuirse a cierta condición ya que es consider= ada como un uropatógeno común en las infecciones del tracto urinario a nivel intrahospitalario, sobre todo en pacientes sometidos a manipulación urológi= ca, uropatía obstructiva o que han recibido antibióticos de amplio espectro (39). Lo que lleva= a suponer que Pseudomona aeruginosa se encuentra en la comunidad debido a que en el servicio de la consulta externa acuden pacientes con sondas vesicales permanentes o con cistectomía. <= /o:p>

Esta investigación puso en notoria evidencia que Citrobacter freundii y Klebsiella spp. se encuentran entre los microorganism= os productores de BLEE más prevalentes al igual que  E. coli que es la causa frecuente de infecciones comunitarias repostado en la literatura hasta el momento (3,4,10,40). En otro estu= dio realizado en Santa Elena–Ecuador Klebsiella ozaenae y E. c= oli son los principales uropatógenos productores de BLEE, a diferencia del estu= dio de Navarro y cols., en México (41). La producció= n de BLEE está estrechamente relacionado con fallas terapéuticas y es un serio problema para el control de infecciones mostrando un alto nivel de resisten= cia a los antimicrobianos utilizados comúnmente y disminuyendo las opciones terapéuticas para tratamientos empíricos (42).

De manera continua, surgen nuevos mecanismos de resistencia antibacteriana dificultando el adecuado tratamiento, en la Unión Europea se estima alreded= or de 25.000 muertes por año a causa de bacterias multirresistentes  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ceAnuovT","properties":{"= formattedCitation":"(20)","plainCitation":"(2= 0)","noteIndex":0},"citationItems":[{"id"= ;:44,"uris":["http://zotero.org/users/9347451/items/T8NHFHX7= "],"itemData":{"id":44,"type":"arti= cle-journal","container-title":"Anales del Sistema Sanitario de Navarra","DOI":"10.23938/assn.0125","ISSN&quo= t;:"1137-6627","issue":"1","page":&= quot;17-26","source":"SciELO","title":&q= uot;Infecciones del tracto urinario. Estudio de sensibilidad antimicrobiana en Navarra","URL":"http://scielo.isciii.es/scielo.php?scri= pt=3Dsci_abstract&pid=3DS1137-66272018000100017&lng=3Des&nrm=3D= iso&tlng=3Des","volume":"41","author"= ;:[{"family":"Aguinaga","given":"A."= ;},{"family":"Gil-Setas","given":"A.&quo= t;},{"family":"Mazón Ramos","given":"A."},{"family":"Alv= aro","given":"A."},{"family":"Garcí= a-Irure","given":"J. J."},{"family":"Navascués","given":"= ;A."},{"family":"Ezpeleta Baquedano","given":"C."}],"accessed":{&q= uot;date-parts":[["2021",12,2]]},"issued":{"d= ate-parts":[["2018",4]]}}}],"schema":"https:/= /github.com/citation-style-language/schema/raw/master/csl-citation.json&quo= t;} (20). En este sent= ido, la OMS, ha desarrollado un escenario donde se estima que para el año 2050 seguirá un continuo incremento de la resistencia a los antibióticos que provocará diez millones de muertes anuales revelando un impacto clínico-económico a nivel mundial; la tasa de morbilidad por este uropatóge= no adquirida en la comunidad está aumentando muy rápidamente del total de infecciones reportadas a nivel mundial más del 30% son debidas a ITU (43–45).

Según Prieto en un estudio realizado en Europa demuestra que el tratamiento de primera línea para las ITUR en la cistitis aguda no complicada según los patrones de sensibilidad es la fosfomicina trometamol y el pivmecillinam con una efectividad del 94,7% sin embargo, el trimetoprim solo deberá considera= rse cuando se conozca que la tasa resistencia de E. coli sea meno= r al 20% (20).

Se observaron resultados similares con respecto a los patrones de resistencia descritos en la presente investigación, determinando que los antibióticos a= los que E. coli mostró mayor resistencia fueron la cefazolina 42,= 4%, sulfametoxazol trimetoprima 40,6%, norfloxacina 38,0%, ácido nalidíxico 34,= 3%, ciprofloxacina 31,4%, de la misma manera que el estudio realizado en Paute = (15) en relación c= on los aminoglucósidos el porcentaje de resistencia se redujo notablemente, ta= nto para la gentamicina 9,3% y amikacina 1,7%.

De igual forma en un estudio en Cuba se confirma que Escherichia col= i es el microorganismo principal causante de las ITU con un 73,3% igualmente,= los aislados mostraron resistencia significativa frente a los antibióticos de u= so hospitalario como la cefazolina; y una mayor sensibilidad ante la cefotaxim= a y ceftriaxona (46).

Esto corresponde con lo que acontece en Latinoamérica que desafortunadamente no = se encuentra exenta de esta problemática, en un estudio realizado en Colombia,= la mayor frecuencia de resistencia en E. coli fue para ampicilina (61%), seguido de ácido nalidíxico y trimetoprim-sulfametoxazol (48%), ciprofloxacina (42%). En Klebsiella spp., la frecuencia de resistenc= ia fue menor con el 23% para trimetoprim-sulfametoxazol, 22% ampicilina-sulbac= tam, 19% cefalotina y 15% ciprofloxacina (4). <= /span>

De la misma manera en Brasil, el antibiótico con mayor prevalencia de resisten= cia bacteriana fue sulfametoxazol-trimetoprim en promedio 46,9%, seguido de cefalotina 46,7%, ácido nalidíxico 27,6% y nitrofurantoina 22,3%  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ajSsbHiG","properties":{"= formattedCitation":"(44)","plainCitation":"(4= 4)","noteIndex":0},"citationItems":[{"id"= ;:38,"uris":["http://zotero.org/users/9347451/items/U97SA8EQ= "],"itemData":{"id":38,"type":"arti= cle-journal","abstract":"Foi realizado um estudo retrospectivo, baseado no banco de dados eletrônico de = um hospital universitário, com objetivo de investigar a prevalência dos germes causadores e suas suscetibilidades aos antibióticos em adultos (idade >18 anos), com infecção do trato urinário atendidos ambulatorialmente. Foram id= entificados 957 exames de urocultura positiva no período entre janeiro de 2000 e dezemb= ro de 2004. Escherichia coli, Proteus mirabillis e Klebsiella sp foram três principais bactérias causadoras. Sulfametoxazol-trimetropim apresentou a ma= ior (46,9%) prevalência de resistência bacteriana seguida por cefalotina (46,7%= ), ácido nalidíxico (27,6%) e nitrofurantoína (22,3%). Durante o período estud= ado, o ácido nalidíxico apresentou um aumento anual de 5,9% na taxa de resistênc= ia bacteriana (p=3D 0,02). Ciprofloxacina mostrou também a tendência de aument= o, com um crescimento anual de 3,3% (p=3D 0,07). Este estudo demonstrou que os antibióticos amplamente recomendados no tratamento empírico da infecção do trato urinário em adultos apresentaram altas taxas de resistência bacterian= a na população estudada.","container-title":"Revista da Sociedade Brasileira de Medicina Tropical","DOI":"10.1590/S0037-86822008000300010",= "ISSN":"0037-8682, 1678-9849","journalAbbreviation":"Rev. Soc. Bras. Med. Trop.","language":"pt","note":"publ= isher: Sociedade Brasileira de Medicina Tropical - SBMT","page":"277-281","source":"Sc= iELO","title":"Resistência antimicrobiana dos uropatógenos em pacientes ambulatoriais, 2000-2004","URL":"http://www.scielo.br/j/rsbmt/a/zsn7FR= wnnvx8VMmzZ3M3LTt/?lang=3Dpt","volume":"41","= author":[{"family":"Koch","given":"= Camila Ribeiro"},{"family":"Ribeiro","given":&q= uot;Juliana Camurça"},{"family":"Schnor","given":&qu= ot;Otávio Haygert"},{"family":"Zimmermann","given"= :"Bruno Sudbrack"},{"family":"Müller","given":&q= uot;Fernanda Melo"},{"family":"D' Agostin","given":"Juliana"},{"family":&q= uot;Machado","given":"Vívian"},{"family"= :"Zhang","given":"Linjie"}],"accessed&qu= ot;:{"date-parts":[["2021",12,3]]},"issued":{= "date-parts":[["2008",6]]}}}],"schema":"= https://github.com/citation-style-language/schema/raw/master/csl-citation.j= son"} (44). <= /span>

En Ecuador, un estudio realizado en la ciudad Quito determinó que E. coli presenta tasas de resistencia a ampicilina >50%, trimetoprim-sulfametoxa= zol >20%, ciprofloxacina 56,8%, con respecto a los aminoglucósidos el porcen= taje de resistencia fue disminuyendo, tanto para la gentamicina 19,4% y amikacin= a 3,6% (9,47). Sin embargo,= en un estudio desarrollado en Lima, Perú, la resistencia a aminoglucósidos se presentó en E. coli (27,1%), Klebsiella pneumoniae (46,7%) y Proteus mirabilis (84,6%) por la producción de enzimas modificadoras siendo estas betalactamasas de espectro extendido (5). <= /span>

En Santo Domingo de los Tsáchilas, Ecuador se realizó un estudio donde se puede observar, de la misma manera que los estudios consultados, que el microorganismo E. coli predomina con un porcentaje de 55,17%, seguid= o de Klebsiella spp. 31,03% Staphylococcus spp. con 10,34% y finalmente con un 4,5% Enterobacter spp. (48). Otro estudio realizado en Ecuador, Azuay en la ciudad de Paute es claro que los datos encontrados en dicho estudio son similares con los demás estudios mencionad= os con el porcentaje para E. coli = de un 69,7% (15).

Entre los antibióticos testeados destacan los carbapenémicos (imipenem y meropene= m), debido a su elevada tasa de sensibilidad alrededor del 97%, lo cual corresp= onde con lo investigado por Linhares y colaboradores quienes determinaron una prevalencia de resistencia de E. coli a imipenem de 0,2% (49), antibiótico = que generalmente no se encuentra entre las primeras o segundas opciones de tratamiento empírico para infecciones de tracto urinario.  

Conclusiones

·      =    Entre las enterobacterias estudiadas, = Escherichia coli es el uropatógeno más frecuente en la población objeto de estud= io, es el principal agente causal de infecciones urinarias en la comunidad, con mayor incidencia en el género femenino. Para el tratamiento empírico la tas= a de resistencia microbiana no debe ser superior al 30% (50). De este modo, según los resultados microbiológicos, se indica que los antibióticos que podrían ser utilizados empíricamente para el tratamiento de la ITU son gentamicina, amikacina, nitrofurantoina. Sin embargo, sería de gran benefic= io que se realicen urocultivos previos a la prescripción médica de antibiótico= s.

·      =    Actualmente también se ha identificado= E. coli BLEE proveniente de la comunidad como agente etiológico de ITU,= lo que traduce un serio problema de salud pública y comprende aspectos como la naturaleza comunitaria del microorganismo causante de la infección y la relación con la atención sanitaria por la necesidad de usar antibióticos de mayor espectro con alto coste.

·      =    Todos estos hallazgos evidenciados en = el presente estudio, se registra en la población de Morona Santiago, específicamente en el Centro Clínico Quirúrgico Ambulatorio Hospital del Día Macas-Ecuador, donde se demuestra que existe diversidad de uropatógenos aislados y la variabilidad de perfiles de resistencia antimicrobiana que justifican la necesidad de fomentar investigaciones locales que permitan estudiar y monitorear los patrones resistencia propios de la localidad para promover la prescripción adecuada de antibióticos orientada a la vigilancia epidemiológica de medicamentos. La presente investigación sugiere la realización de estudios prospectivos que evalúen el impacto de los diferent= es antibióticos sobre la evolución clínica de los pacientes con ITU, a fin de establecer nuevos protocolos de manejo que sean ajustados al comportamiento regional de esta patología.

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 <= /p>

El artículo= que se publica es de exclusiva responsabilidad de los autores y no necesariamen= te reflejan el pensamiento de la Revi= sta Anatomía Digital.


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El artículo queda en propiedad de la revista y, por tanto, su publicación parc= ial y/o total en otro medio tiene que ser autorizado por el director de la R= evista Anatomía Digital.

 

 


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ISSN: 2697-3391=

Vol. 5 No. 4.1, pp. 63= – 83, noviembre 2022

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                                      Medicina Molecular               Página 63 | 1

 

 

                                      Ingeniería Genética               Página 63 | 1

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