ﺍﻟﻤﻌﺯﻭﻟﺔ ﻤﺤﻠﻴﺎ ﻤﻥ ﺍﻟﺘﻬﺎﺒﺎﺕ ﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩ ﻟﺒﻜﺘ K
ﺍﻟﻤﺠﻠﺔ ﺍﻟﻌﺭﺍﻗﻴﺔ ﻟﻠﻌﻠﻭﻡ ،ﺍﻟﻤﺠﻠﺩ ،٥١ﺍﻟﻌﺩﺩ ،٢٠١٠ ،٣ﺍﻟﺼﻔﺤﺔ ٤٢١-٤١٥ ﻓﺭﺝ ﻭﻏﻨﻴﻤﺔ ﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩ ﻟﺒﻜﺘﺭﻴﺎ Klebsiella pneumoniaeﺍﻟﻤﻌﺯﻭﻟﺔ ﻤﺤﻠﻴﺎ ﻤﻥ ﺍﻟﺘﻬﺎﺒﺎﺕ ﺍﻟﻤﺠﺎﺭﻱ ﺍﻟﺒﻭﻟﻴﺔ ﻭﺩﻭﺭﻩ ﻓﻲ ﺍﻟﻤﻘﺎﻭﻤﺔ ﺍﻟﻤﺘﻌﺩﺩﺓ ﻟﻠﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﺩﻴﻤﺔ ﻨﺯﺍﺭ ﻓﺭﺝ* ،ﻗﻴﺱ ﻗﺎﺴﻡ ﻏﻨﻴﻤﺔ ﻗﺴﻡ ﻋﻠﻭﻡ ﺍﻟﺤﻴﺎﺓ ،ﻜﻠﻴﺔ ﺍﻟﻌﻠﻭﻡ ،ﺠﺎﻤﻌﺔ ﺒﻐﺩﺍﺩ .ﺒﻐﺩﺍﺩ-ﺍﻟﻌﺭﺍﻕ. *ﻤﻌﻬﺩ ﺍﻟﻬﻨﺩﺴﺔ ﺍﻟﻭﺭﺍﺜﻴﺔ ﻭﺍﻟﺘﻘﻨﻴﺎﺕ ﺍﻻﺤﻴﺎﺌﻴﺔ ﻟﻠﺩﺭﺍﺴﺎﺕ ﺍﻟﻌﻠﻴﺎ ،ﺠﺎﻤﻌﺔ ﺒﻐﺩﺍﺩ .ﺒﻐﺩﺍﺩ-ﺍﻟﻌﺭﺍﻕ. ﺍﻟﺨﻼﺼﺔ ﺩﺭﺴﺕ ﻋﻤﻠﻴﺔ ﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩ ﻟﺴﺒﻊ ﻋﺯﻻﺕ ﻤﺤﻠﻴﺔ ﻟﺒﻜﺘﺭﻴﺎ Klebsiella pneumoniaeﺍﻟﻤﺘﻌﺩﺩﺓ ﺍﻟﻤﻘﺎﻭﻤﺔ ﻟﻠﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﻭﺍﻟﻤﻌﺯﻭﻟﺔ ﻤﻥ ﺤﺎﻻﺕ ﺍﻟﺘﻬﺎﺒﺎﺕ ﺍﻟﻤﺠﺎﺭﻱ ﺍﻟﺒﻭﻟﻴﺔ ﺒﺎﺴﺘﺨﺩﺍﻡ ﻤﺎﺩﺘﻲ ﺍﻟـ Acridin orangeﻭﺍﻟـ .(SDS) Sodium dodecyl sulphate ﺃﻅﻬﺭﺕ ﺍﻟﻨﺘﺎﺌﺞ ﺍﻥ ﺍﻟﻌﺯﻻﺕ ﺍﻟﻤﺤﻠﻴﺔ ﻟﺠﺭﺜﻭﻤﺔ K.pneumoniaeﻜﺎﻨﺕ ﺫﺍﺕ ﻤﻘﺎﻭﻤﺔ ﻋﺎﻟﻴﺔ ﺠﺩﺍ ًﺍﺫ ﺒﻠﻐﺕ ) (%100ﻟﻤﻀﺎﺩﺍﺕ ﺍﻤﺒﻴﺴﻴﻠﻴﻥ،ﺒﺒﺭﺍﺴﻴﻠﻴﻥ ،ﺍﻤﻭﻜﺴﻴﺴﻴﻠﻴﻥ ،ﺒﻨﺴﻠﻴﻥ ﺝ ،ﺘﺘﺭﺍﺴﺎﻴﻜﻠﻴﻥ ،ﺍﺭﺜﺭﻭﻤﺎﻴﺴﻴﻥ ﻭﺠﻨﺘﺎﻤﺎﻴﺴﻴﻥ ﻭﺍﻅﻬﺭﺕ ﻤﻘﺎﻭﻤﺔ ﻋﺎﻟﻴﺔ ) (%86–71ﻟﻤﻀﺎﺩﺍﺕ ﺴﻴﻔﺎﻟﻴﻜﺴﻴﻥ ،ﺴﻴﻔﺎﻟﻭﺜﻴﻥ ،ﺴﻴﻔﺘﺎﺯﺩﻴﻡ ،ﺴﺒﺭﻭﻓﻠﻭﻜﺴﺎﺴﻴﻥ، ﺴﺘﺭﺒﺘﻭﻤﺎﻴﺴﻴﻥ ﻭﺍﻟﺘﻭﺒﺭﺍﻤﺎﻴﺴﻴﻥ ،ﻭﻤﻘﺎﻭﻤﺔ ﻤﺘﻭﺴﻁﺔ ) (%57–43ﻟﻤﻀﺎﺩﺍﺕ ﺴﻴﻔﺎﻜﻠﻭﺭ ،ﺴﻴﻔﺭﺍﺩﻴﻥ ،ﻭﻨﺎﻟﺩﻜﺴﻙ ﺍﺴﻴﺩ ،ﻓﻲ ﺤﻴﻥ ﺍﻨﻬﺎ ﺍﻅﻬﺭﺕ ﻤﻘﺎﻭﻤﺔ ﻀﻌﻴﻔﺔ ) (%29ﻟﻤﻀﺎﺩ ﺴﻴﻔﻭﺘﺎﻜﺴﻴﻡ ﻭﺍﻨﻬﺎ ﻜﺎﻨﺕ ﺤﺴﺎﺴﺔ ﻟﻤﻀﺎﺩﺍﺕ ﻜﻠﻭﺭﺍﻤﻔﻴﻨﻴﻜﻭل ﻭﺍﻤﻴﻜﺎﺴﻴﻥ. ﻭﻤﻥ ﺨﻼل ﻋﻤﻠﻴﺔ ﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩ ﻭﺠﺩ ﺍﻥ ﻤﺎﺩﺓ ﺍﻟـ SDSﺍﻜﺜﺭ ﻜﻔﺎﺀﺓ ﻓﻲ ﺍﺤﺩﺍﺙ ﺍﻟﺘﺤﻴﻴﺩ ﻤﻘﺎﺭﻨﺔ ﺒﺎﻟـ orange Acridineﺤﻴﺙ ﻟﻭﺤﻅ ﻓﻘﺩﺍﻥ ﺍﻟﻤﻘﺎﻭﻤﺔ ﻟﻠﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﺒﺎﻟﻨﺴﺒﺔ ﻟﻠـ SDSﺒﻤﺩﻯ )–70 (%100ﺍﻤﺎ ﺒﺎﻟﻨﺴﺒﺔ ﻟﻠـ Acridineﻓﻜﺎﻨﺕ ) ،(%100–28ﻭﺒﻌﺩ ﻋﻤﻠﻴﺔ ﺍﻟﺘﺤﻴﻴﺩ ﻓﻘﺩﺕ ﺍﻟﻤﻘﺎﻭﻤﺔ ﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺒﺒﺭﺍﺴﻴﻠﻴﻥ ،ﺍﻤﻭﻜﺴﻴﺴﻴﻠﻴﻥ ،ﺒﻨﺴﻠﻴﻥ ﺝ ،ﺴﻴﻔﺎﻟﻴﻜﺴﻴﻥ ،ﺴﻴﻔﺎﻟﻭﺜﻴﻥ،ﺴﻴﻔﺘﺎﺯﺩﻴﻡ ،ﺘﺘﺭﺍﺴﺎﻴﻜﻠﻴﻥ ،ﺠﻨﺘﺎﻤﺎﻴﺴﻴﻥ ﻭﺘﻭﺒﺭﺍﻤﺎﻴﺴﻴﻥ ﻤﻤﺎ ﻴﺩل ﻋﻠﻰ ﺍﻥ ﺼﻔﺔ ﻤﻘﺎﻭﻤﺔ ﻫﺫﻩ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﻤﺤﻤﻭﻟﺔ ﻋﻠﻰ ﺍﻟﺒﻼﺯﻤﻴﺩ ﻓﻲ ﺤﻴﻥ ﻟﻡ ﺘﻔﻘﺩ ﻤﻘﺎﻭﻤﺔ ﻤﻀﺎﺩﺍﺕ ﺍﻻﻤﺒﻴﺴﻴﻠﻴﻥ ،ﺴﺒﺭﻭﻓﻠﻭﻜﺴﺎﺴﻴﻥ ،ﺍﺭﺜﺭﻭﻤﺎﻴﺴﻴﻥ ﻭﺴﺘﺭﺒﺘﻭﻤﺎﻴﺴﻴﻥ ﻤﻤﺎ ﻴﺩل ﻋﻠﻰ ﺍﻥ ﺍﻟﻤﻭﺭﺜﺎﺕ ﺍﻟﺘﻲ ﺘﺸﻔﺭ ﻟﻤﻘﺎﻭﻤﺘﻬﺎ ﻤﺤﻤﻭﻟﺔ ﻋﻠﻰ ﺍﻟﻜﺭﻭﻤﻭﺴﻭﻡ. PLASMID CURING OF LOCAL ISOLATES OF KLEBSIELLA PNEUMONIAE ISOLATED FROM URINARY TRACT INFECTIONS AND ITS ROLE IN MULTIDRUG RESISTANCE *Dimah Nazar Faraj, Kais Kassim Ghanima Department of Biology, College of Science, University of Baghdad. * Institute of Genetic Engineering and Biotechnology for Postgraduate Studies, University of Baghdad ﺍﻟﻤﺠﻠﺔ ﺍﻟﻌﺭﺍﻗﻴﺔ ﻟﻠﻌﻠﻭﻡ ،ﺍﻟﻤﺠﻠﺩ ،٥١ﺍﻟﻌﺩﺩ ،٢٠١٠ ،٣ﺍﻟﺼﻔﺤﺔ ٤٢١-٤١٥ ﻓﺭﺝ ﻭﻏﻨﻴﻤﺔ Abstract Curing of plasmid for 7 local isolates of K. pneumoniae have multi-drug resistance and isolated from urinary tract infections (UTI) by using acridin orange and sodium dodecyl sulphate (SDS) were investigated. These results showed that the local isolates of K. pneumoniae were very resist (100%) to Ampicillin, Pepracillin, Amoxicillin, Penicillin G, Tetracyclin, Erythromycin and Gentamycin, high resist (71–80%) to Cephalexin, Cephalothin, Ceftazidine, Ciprofloxacin, Streptomycin and Tobramycin, moderate resist (43–57%) to Cefaclor, Cephradin and Naldixic acid and weak resist (29%) to Cefotaxime while they were susceptible to Chloramphenicol and Amikacin. t was found that SDS is more efficient in curing than Acridin orange, hence the )losing of the resistance of antibiotics by using SDS was in the range (70–100% while by using Acridin orange was in the range (28– 100%). After curing of plasmid the Antibiotics resistance losed for Pipracillin, Amoxicillin, Penicillin G, Cephalexin, Cephalothin, Ceftazidin, Tetracyclin, Gentamycin and Tobramycin, this result confirm that the resistance of these antibiotics is born on plasmid, while the resistance of Ampicillin, Ciprofloxacin, Erythromycin and Streptomycin not losed, this result confirm that there resistance genes are born on the chromosome. ﺍﻟﻤﻘﺩﻤﺔ ﺘﻌﺩ ﺒﻜﺘﺭﻴﺎ Klebsiella pneumoniaeﻤﻥ ﺍﻟﻌﺼـﻴﺎﺕ ﺍﻟﻤﻤﺭﻀﺔ ﺍﻟﺴﺎﻟﺒﺔ ﻟﺼﺒﻐﺔ ﻜﺭﺍﻡ ﺍﻨﺘﻬﺎﺯﻴﺔ ﻟﻠﻔﺭﺹ ﺘﺴـﺎﻫﻡ ﻓـﻲ ﺍﺤﺩﺍﺙ ﺍﻟﻌﺩﻴﺩ ﻤﻥ ﺍﺼﺎﺒﺎﺕ ﺍﻟﺠﻬﺎﺯ ﺍﻟﺘﻨﻔﺴﻲ ﺍﻟﺴﻔﻠﻲ ﻭﺍﻟﻤﺠـﺎﺭﻱ ﺍﻟﺒﻭﻟﻴﺔ ﻭﺍﺼﺎﺒﺎﺕ ﺍﻟﺠﺭﻭﺡ ﻭﺍﻟﺤﺭﻭﻕ ] ،[١ﻭﻫﺫﻩ ﺍﻟﺒﻜﺘﺭﻴﺎ ﺘـﺄﺘﻲ ﺒﺎﻟﻤﺭﺘﺒﺔ ﺍﻟﺜﺎﻨﻴﺔ ﻤﻥ ﻤﺴﺒﺒﺎﺕ ﺍﻟﺘﻬﺎﺒﺎﺕ ﺍﻟﻤﺠﺎﺭﻱ ﺍﻟﺒﻭﻟﻴـﺔ ﺒﻌـﺩ ﺒﻜﺘﺭﻴﺎ ﺍﻟـ .[2] Escherichia coli ﺘﺤﻭﻱ ﺍﻟﻌﺩﻴﺩ ﻤﻥ ﺍﻟﻌﺼﻴﺎﺕ ﺍﻟﺴﺎﻟﺒﺔ ﻟﺼﺒﻐﺔ ﻜـﺭﺍﻡ ﺒﻼﺯﻤﻴـﺩﺍﺕ ﺘﺤﻤل ﻤﻭﺭﺜـﺎﺕ ﺍﻟﻤﻘﺎﻭﻤـﺔ ﻟﻤﻀـﺎﺩﺍﺕ ﺍﻻﻤﻴﻨﻭﻜﻼﻴﻜﻭﺴـﺎﻴﺩ، ﺍﻟﻜﻠﻭﺭﺍﻤﻔﻴﻨﻜﻭل ،ﺍﻟﺴﻠﻔﻭﻨﺎﻤﺎﻴﺩ ،ﺍﻟﺘﺭﺍﻴﻤﻴﺜﻭﺒﺭﻴﻡ ﻭﺍﻟﺘﺘﺭﺍﺴـﺎﻴﻜﻠﻴﻥ، ﻭﻓﻲ ﺍﻨﻭﺍﻉ ﺒﻜﺘﺭﻴﺎ ﺍﻟـ Klebsiellaﺘﻭﺠﺩ ﺍﻨﻭﺍﻉ ﻤﺨﺘﻠﻔﺔ ﻤـﻥ ﺍﻟﺒﻼﺯﻤﻴﺩﺍﺕ ﺍﻟﺘﻲ ﺘﺸﻔﺭ ﻻﻨﺯﻴﻤﺎﺕ ﺍﻟﺒﻴﺘﺎﻻﻜﺘﺎﻤﻴﺯ ﻭﺍﺴﻌﺔ ﺍﻟﻁﻴﻑ ﺍﻟﻤﺴﺅﻭﻟﺔ ﻋﻥ ﺍﻟﻤﻘﺎﻭﻤﺔ ﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺒﻴﺘﺎ ﻻﻜﺘﺎ ] ،[٣ﻭﺍﻟﺠـﺭﺍﺜﻴﻡ ﺍﻟﻤﺘﻌﺩﺩﺓ ﺍﻟﻤﻘﺎﻭﻤﺔ ﻟﻠﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﻋﺎﺩﺓ ﻤـﺎﺘﺤﻭﻱ ﺠﻴﻨـﺎﺕ ﻗﺎﻓﺯﺓ ﻤﺘﻌﺩﺩﺓ ﻭﺒﻼﺯﻤﻴﺩﺍﺕ ﺘﺤﻤل ﻤﺤﺩﺩﺍﺕ ﻭﺭﺍﺜﻴﺔ ﻟﻤﻴﻜﺎﻨﻴﻜﻴـﺎﺕ ﻤﺨﺘﻠﻔﺔ ﻤﻥ ﺍﻟﻤﻘﺎﻭﻤﺔ ﺘﺠﻌل ﻤﻥ ﻋﻤﻠﻴﺔ ﺍﻟﻌﻼﺝ ﺒﺎﻟﻤﻀﺎﺩﺍﺕ ﺼﻌﺒﺔ ﺠﺩﹰﺍ ﻭﻗﺩ ﻴﻘﻭﺩ ﺫﻟﻙ ﺍﻟﻰ ﺍﺴﺘﺨﺩﺍﻡ ﻤﻀـﺎﺩﺍﺕ ﻭﺍﺴـﻌﺔ ﺍﻟﻁﻴـﻑ ﺒﺎﻫﻀﺔ ﺍﻟﺜﻤﻥ ] [4ﻭﻴﻤﻜﻥ ﻟﺨﻼﻴﺎ ﺍﻟﺒﻜﺘﺭﻴﺎ ﺍﻥ ﺘﻔﻘﺩ ﺍﻟﺒﻼﺯﻤﻴـﺩﺍﺕ ﺘﻠﻘﺎﺌﻴﹰﺎ ﻭﻟﻜﻥ ﺒﺘﺭﺩﺩﺍﺕ ﻭﺍﻁﺌﺔ ﻭﻫﺫﻩ ﺍﻟﻅـﺎﻫﺭﺓ ﺘﺴـﻤﻰ ﺍﻟﺘﺤﻴﻴـﺩ ﺍﻟﺘﻠﻘﺎﺌﻲ ﻭﺒﺎﻻﻤﻜﺎﻥ ﺯﻴﺎﺩﺓ ﺘﺭﺩﺩ ﻓﻘﺩﺍﻥ ﺍﻟﺒﻼﺯﻤﻴﺩﺍﺕ ﻋﻨﺩ ﺘﻌﺭﺽ ﺍﻟﺨﻼﻴﺎ ﺍﻟﻰ ﻤﺭﻜﺒﺎﺕ ﺘﺤﺸﺭ ﻨﻔﺴﻬﺎ ﺒـﻴﻥ ﻗﻭﺍﻋـﺩ ﺍﻟــ DNA ﻭﺒﺸﻜل ﺨﺎﺹ ﺍﻻﻜﺭﺩﻴﻨﺎﺕ ﻤﺜل ﺍﻟــ Ethidium bromide ﻭﺍﻟـ Acridineﺍﻭ ﺒﺎﺴـﺘﺨﺩﺍﻡ ﻤـﻭﺍﺩ ﻤﺜـل ﺍﻟــ )(SDS .[5] Sodium dodecyl sulphate ﺍﺴﺘﻬﺩﻓﺕ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺴﺔ ﺍﻟﺤﺼﻭل ﻋﻠﻰ ﻋﺯﻻﺕ ﻤﺤﻠﻴﺔ ﻟﺒﻜﺘﺭﻴـﺎ Klebsiella pneumoniaeﻤﻥ ﻋﻴﻨﺎﺕ ﺍﻟﺘﻬﺎﺒﺎﺕ ﺍﻟﻤﺠـﺎﺭﻱ ﺍﻟﺒﻭﻟﻴﺔ ﻭﺘﺸﺨﻴﺼﻬﺎ ﻭﺩﺭﺍﺴﺔ ﻤﻘﺎﻭﻤﺘﻬﺎ ﻟﻤﺠﻤﻭﻋﺔ ﻤﺨﺘـﺎﺭﺓ ﻤـﻥ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ،ﻭﺍﻟﻌﻼﻗﺔ ﺒـﻴﻥ ﻫـﺫﻩ ﺍﻟﻤﻘﺎﻭﻤـﺔ ﻭﻭﺠـﻭﺩ ﺍﻟﺒﻼﺯﻤﻴﺩ ﻋﻥ ﻁﺭﻴﻕ ﺍﺠﺭﺍﺀ ﻋﻤﻠﻴﺔ ﺍﻟﺘﺤﻴﻴـﺩ ﻟﻠﺒﻼﺯﻤﻴـﺩ ﻓـﻲ ﻋﺯﻻﺕ ﻫﺫﻩ ﺍﻟﺒﻜﺘﺭﻴﺎ ﺒﺎﺴـﺘﺨﺩﺍﻡ ﺒﻌـﺽ ﺍﻟﻌﻭﺍﻤـل ﺍﻟﻜﻴﻤﻴﺎﺌﻴـﺔ ﻭﻤﻘﺎﺭﻨﺔ ﺍﻟﻨﺘﺎﺌﺞ. ﺍﻟﻤﻭﺍﺩ ﻭﻁﺭﺍﺌﻕ ﺍﻟﻌﻤل ﺍﻟﻌﺯل ﻭﺍﻟﺘﺸﺨﻴﺹ ﺠﻤﻌﺕ 150ﻋﻴﻨﺔ ﻤﻥ ﻋﻴﻨﺎﺕ ﺍﻟﺒﻭل )ﻟﻠﻨﺴﺎﺀ ﻭﺍﻟﺭﺠﺎل ﻤﻥ ﻋﻤﺭ 50 –20ﺴﻨﺔ( ﻤﻥ ﻤﺴﺘﺸﻔﻰ ﺍﻟﻜﻨﺩﻱ ﺍﻟﺘﻌﻠﻴﻤﻲ ﺨﻼل ﺍﻟﻤﺩﺓ ﻤﻥ ﺸﻬﺭ ﻜﺎﻨﻭﻥ ﺍﻟﺜﺎﻨﻲ ﺍﻟﻰ ﺸﻬﺭ ﻨﻴﺴﺎﻥ ﻟﻠﻌﺎﻡ 2007ﻓﻲ ﺍﻭﻋﻴﺔ ﺒﻼﺴﺘﻴﻜﻴﺔ ﻤﻌﻘﻤﺔ ﻭﺯﺭﻋﺕ ﻤﺒﺎﺸﺭﺓ ﺒﺎﺴﺘﺨﺩﺍﻡ ﻨﺎﻗل ﺯﺭﻉ ﻤﻌﻘـﻡ ﻋﻠﻰ ﺍﻭﺴﺎﻁ ﺍﻜﺎﺭ ﺍﻟﺩﻡ ﻭﺍﻜﺎﺭ ﻤﺎﻜﻭﻨﻜﻲ )ﺍﻟﻤﺠﻬﺯﺓ ﻤـﻥ ﺸـﺭﻜﺔ Himediaﺍﻟﻬﻨﺩﻴﺔ( ﻭﺤﻀﻨﺕ ﻋﻨﺩ ﺩﺭﺠﺔ ﺤﺭﺍﺭﺓ 37°ﻡ ﻟﻤـﺩﺓ 24ﺴﺎﻋﺔ ﻭﺸﺨﺼﺕ ﺍﻟﺒﻜﺘﺭﻴـﺎ ﺒﺎﻻﻋﺘﻤـﺎﺩ ﻋﻠـﻰ ﺍﻟﺼـﻔﺎﺕ ﺍﻟﺘﺸﺨﻴﺼﻴﺔ ﺍﻟﺨﺎﺼﺔ ﺒﺎﻟﺒﻜﺘﺭﻴﺎ ] [٧ ،٦ﻭﻟﻠﺘﺄﻜـﺩ ﻤـﻥ ﺼـﺤﺔ ﺍﻟﺘﺸﺨﻴﺹ ﺘﻡ ﺍﺴﺘﺨﺩﺍﻡ ﻨﻅﺎﻡ ﺍﻟﺘﺸﺨﻴﺹ .API-20E ﺍﺨﺘﺒﺎﺭ ﺍﻟﺤﺴﺎﺴﻴﺔ ﻟﻠﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﺎﺘﻴﺔ ﺍﺴﺘﺨﺩﻤﺕ ﻁﺭﻴﻘﺔ ﺍﻻﻨﺘﺸﺎﺭ ﻋﻠﻰ ﺴﻁﺢ ﺍﻜﺎﺭ ﻤﻭﻟﺭ -ﻫﻨﺘﻭﻥ )ﺍﻟﻤﺠﻬﺯﻤﻥ ﺸﺭﻜﺔ Himediaﺍﻟﻬﻨﺩﻴﺔ( ﺒﺎﺴـﺘﺨﺩﺍﻡ ﺍﻻﻗـﺭﺍﺹ ) [8] (Disc-diffusion methodﻻﺨﺘﺒﺎﺭ ﺤﺴﺎﺴﻴﺔ ﺒﻜﺘﺭﻴـﺎ K.Pneumaniaeﻟﻠﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﺤﻴـﺙ ﻟﻘـﺢ ﺍﻟﻭﺴـﻁ ﺒﺎﺴﺘﺨﺩﺍﻡ ﻤﺴﺤﺔ ﻗﻁﻨﻴﺔ ﻤﻥ ﻟﻘﺎﺡ ﻋﺩﺩ ﺍﻟﺨﻼﻴﺎ ﺍﻟﺠﺭﺜﻭﻤﻴـﺔ ﻓﻴـﻪ ١٠٨ × ١.٥ﺨﻠﻴﺔ /ﻤﻠﻠﺘﺭ ﻭﻭﻀـﻌﺕ ﺍﻗـﺭﺍﺹ ﺍﻟﻤﻀـﺎﺩﺍﺕ ﺍﻟﻤﺠﻠﺔ ﺍﻟﻌﺭﺍﻗﻴﺔ ﻟﻠﻌﻠﻭﻡ ،ﺍﻟﻤﺠﻠﺩ ،٥١ﺍﻟﻌﺩﺩ ،٢٠١٠ ،٣ﺍﻟﺼﻔﺤﺔ ٤٢١-٤١٥ ﻓﺭﺝ ﻭﻏﻨﻴﻤﺔ ﺍﻟﺤﻴﻭﻴﺔ ﻭﺤﻀﻨﺕ ﺍﻻﻁﺒﺎﻕ ﺒﺩﺭﺠﺔ ﺤـﺭﺍﺭﺓ ْ 37ﻡ ﻟﻤـﺩﺓ 24 ﺍﻋﻭﺍﺩ ﺨﺸﺒﻴﺔ ﻭﺒﻁﺭﻴﻘﺔ ) (Pickand Patchﺍﻟﻰ ﺍﻁﺒـﺎﻕ ﻤـﻥ ﺴﺎﻋﺔ .ﻭﻴﻭﻀـﺢ ﺍﻟﺠـﺩﻭل ١ﺍﻨـﻭﺍﻉ ﺍﻟﻤﻀـﺎﺩﺍﺕ ﺍﻟﺤﻴﺎﺘﻴـﺔ ﺍﻻﻜﺎﺭ ﺍﻟﻤﻐﺫﻱ ﺍﻟﺤﺎﻭﻱ ﻋﻠﻰ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﻪ ﻗﻴﺩ ﺍﻟﺩﺭﺍﺴـﺔ ﺒﺎﻟـ µg / mlﻭﺍﻟﺸﺭﻜﺔ ﺍﻟﻤﺼﻨﻌﺔ ﻟﻬﺎ. ﺍﻟﺒﻜﺘﺭﻴﺎ ﻭﺤﻀﻨﺕ ﺍﻻﻁﺒﺎﻕ ﻋﻨﺩ ﺩﺭﺠﺔ ﺤﺭﺍﺭﺓ °37ﻡ ﻟﻤﺩﺓ 24 ـﺎ ـﺘﺨﺩﻤﺔ ﻭﺘﺭﺍﻜﻴﺯﻫــــــــــ ﺍﻟﻤﺴــــــــــ ﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩﺍﺕ ﺒﺎﺴﺘﺨﺩﺍﻡ ﺼﺒﻐﺔ ﺍﻟـ Acridine orange ﺍﺘﺒﻌﺕ ﻁﺭﻴﻘﺔ [9] Trevorsﻓﻲ ﻤﻌﺎﻤﻠﺔ ﻋﺯﻻﺕ ﺒﻜﺘﺭﻴـﺎ K.pneumoniaeﺒﻭﺴﺎﻁﺔ ﺼﺒﻐﺔ ﺍﻟــ Acridine orange )ﺍﺫ ﺘﻡ ﺍﺨﺘﻴﺎﺭ ﺘﺭﻜﻴﺯ ﺍﻟﺼﺒﻐﺔ ﺍﻟﺘﻲ ﺴﺒﻘﺕ ﺍﻟﺘﺭﻜﻴﺯ ﺍﻟﻤﺜﺒﻁ ﺍﻻﺩﻨﻰ ﻻﺨﺘﺒﺎﺭ ﺍﻟﺘﺤﻴﻴﺩ ﻭﺍﻟﻤﺘﻤﺜل ﺒﺎﻟﺘﺭﻜﻴﺯ 120 µg/mlﻭﺍﻟﺘﻲ ﻴﻜـﻭﻥ ﻋﺩﺩ ﺍﻟﺨﻼﻴﺎ ﺍﻟﺤﻲ ﺍﻗﺭﺏ ﺍﻟﻰ ﺍﻟﺴﻴﻁﺭﺓ ﻏﻴﺭ ﺍﻟﻤﻌﺎﻤﻠﺔ(. ﺠﺩﻭل :١ﺍﺴﻤﺎﺀ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﺍﻟﻤﺴﺘﺨﺩﻤﺔ ﻭﺘﺭﻜﻴﺯﻫﺎ ﻭﺍﻟﺸﺭﻜﺔ ﺍﻟﻤﺼﻨﻌﺔ ﻟﻬﺎ. ﺍﺴﻡ ﺍﻟﻤﻀﺎﺩ code ﺘﺭﻜﻴﺯﻩ µg/ml ﺍﻟﺸﺭﻜﺔ ﺍﻟﻤﺼﻨﻌﺔ Ampicillin Pepracillin Amoxicillin Penicillin G Cephalexin Cephalothin Cefaclor Cephradine Cefotaxime Cephtazidine Ciprofloxacin Tetracyclin Chloramphenicol Erythromycin Gentamicin Streptomycin Tobramycin Nalidixic acid Amikacin AM PRL AX P CI CF CEC CE CTX CTZ CIP TE C E G S Tob NA AK 10 100 25 10 30 30 30 30 30 30 10 30 10 15 50 26 30 30 10 AL-Razi AL-Razi AL-Razi AL-Razi Oxoid Oxoid Oxoid Oxoid Bioanalyse Bioanalyse Oxoid Bioanalyse Bioanalyse Bioanalyse Bioanalyse Bioanalyse Bioanalyse Bioanalyse Oxoid ﺠﻬﺯ ﻫﺫﺍ ﺍﻟﺘﺭﻜﻴﺯ ﻓﻲ 5ﻤﻠﻠﺘﺭ ﻤﻥ ﺍﻟﻤﺭﻕ ﺍﻟﻤﻐﺫﻱ ﻭﺘﺭﻙ ﺍﻨﺒﻭﺏ ﻤﻥ ﺩﻭﻥ ﺍﻀﺎﻓﺔ ﺍﻟﺼﺒﻐﺔ ﻜﺴﻴﻁﺭﺓ ﻭﻟﻘﺤﺕ ﺍﻻﻨﺎﺒﻴﺏ ﺒﺤﻭﺍﻟﻲ104 ﺨﻠﻴﺔ /ﻤﻠﻠﺘﺭ ﻭﺤﻀﻨﺕ ﺒﺩﺭﺠﺔ ﺤﺭﺍﺭﺓ °37ﻡ ﻟﻤﺩﺓ 24ﺴـﺎﻋﺔ ﺜﻡ ﻋﻤﻠﺕ ﺘﺨﺎﻓﻴﻑ ﻟﺠﻤﻴﻊ ﺍﻟﻤﺯﺍﺭﻉ ﺍﻟﻤﻌﺎﻤﻠﺔ ﻭﺍﻟﺴﻴﻁﺭﺓ ﻏﻴـﺭ ﺍﻟﻤﻌﺎﻤﻠﺔ ﺤﻴﺙ ﺨﻔﻑ ﺍﻟﻤﺯﺭﻭﻉ ﺍﻟﻰ 10-7 ،10-6 ،10-5ﻭﻨﺸـﺭ ﻤﻘﺩﺍﺭ 0.2ﻤﻠﻠﺘﺭ ﻋﻠﻰ ﻭﺴﻁ ﺍﻻﻜﺎﺭ ﺍﻟﻤﻐﺫﻱ ﺍﻟﺼﻠﺏ ﻭﺤﻀـﻥ ﺒﺩﺭﺠﺔ ﺤـﺭﺍﺭﺓ °37ﻡ ﻟﻤـﺩﺓ 24ﺴـﺎﻋﺔ ﺍﻭ ﺤﺘـﻰ ﻅﻬـﻭﺭ ﻤﺴﺘﻌﻤﺭﺍﺕ ﻭﺍﻀﺤﺔ ،ﺒﻌﺩﻫﺎ ﺘﻡ ﻨﻘل 100ﻤﺴـﺘﻌﻤﺭﺓ ﺒﻭﺴـﺎﻁﺔ )ﻭﺒﻨﻔﺱ ﺍﻟﺘﺭﺍﻜﻴﺯ ﺍﻟﻤﺴﺘﺨﺩﻤﺔ ﻓﻲ ﺍﻻﻗﺭﺍﺹ( ﻭﺍﻟﺘـﻲ ﻗﺎﻭﻤﺘﻬـﺎ ﺴﺎﻋﺔ ﻭﺘﻡ ﻤﻼﺤﻅﺔ ﺍﻟﻨﺘﺎﺌﺞ ﻭﻟﻐﺭﺽ ﺍﻟﺘﻌـﺭﻑ ﻋﻠـﻰ ﺍﻟﺨﻼﻴـﺎ ﺍﻟﻤﺤﻴﺩﺓ ﻓﺎﻨﻨﺎ ﻨﻼﺤﻅ ﻋﺩﻡ ﻅﻬﻭﺭ ﻨﻤﻭ ﻋﻠـﻰ ﻭﺴـﻁ ﺍﻟﻤﻀـﺎﺩ ﻭﻅﻬﻭﺭﻩ ﻋﻠﻰ ﺍﻟﻭﺴﻁ ﺍﻟﺨﺎﻟﻲ ﻤﻥ ﺍﻟﻤﻀﺎﺩ ﻭﻫﺫﺍ ﻴﻌﻨﻲ ﺍﻥ ﺍﻟﺨﻠﻴﺔ ﻓﻘﺩﺕ ﺼﻔﺔ ﻤﻘﺎﻭﻤﺔ ﺫﻟﻙ ﺍﻟﻤﻀﺎﺩ. ﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩﺍﺕ ﺒﺎﺴﺘﺨﺩﺍﻡ Sodium dodecyl (SDS) sulphate ﺍﺘﺒﻌﺕ ﻁﺭﻴﻘﺔ Marceloﻭﺠﻤﺎﻋﺘﻪ ] [10ﻓـﻲ ﻤﻌﺎﻤﻠـﺔ ﻋﺯﻻﺕ ﺒﻜﺘﺭﻴﺎ K. pneumoniaeﺒﻭﺴﺎﻁﺔ ﺍﻟـ SDSﺤﻴـﺙ ﺘﻡ ﺍﺨﺘﻴﺎﺭ ﺍﻟﺘﺭﻜﻴﺯ ) ،(%1ﻟﻘﺢ 5ﻤﻠﻠﺘﺭ ﻤـﻥ ﻭﺴـﻁ ﺍﻟﻤـﺭﻕ ﺍﻟﻤﻐﺫﻱ ﺒﻤﺴﺘﻌﻤﺭﺓ ﻤﻥ ﺒﻜﺘﺭﻴﺎ K. pneumoniaeﻭﺤﻀﻥ ﻋﻨﺩ ﺩﺭﺠﺔ 37ﻡ ﻟﻤﺩﺓ 24ﺴﺎﻋﺔ ﺜﻡ ﻟﻘﺢ 5ﻤﻠﻠﺘﺭ ﻤﻥ ﻭﺴﻁ ﺍﻟﻤـﺭﻕ ﺍﻟﻤﻐﺫﻱ ﺍﻟﺤﺎﻭﻱ ﻋﻠﻰ ﺍﻟـ SDSﺒﺘﺭﻜﻴﺯ ﻨﻬﺎﺌﻲ %١ﺒﺤـﻭﺍﻟﻲ 104ﺨﻠﻴﺔ/ﻤﻠﻠﺘﺭ ﻤﻥ ﺍﻟﻤﺯﺭﻋﺔ ﺍﻟﺠﺭﺜﻭﻤﻴﺔ ﺍﻟﻤﺤﻀـﺭﺓ ﻤﺴـﺒﻘﹰﺎ ﻭﺤﻀﻨﺕ ﺍﻻﻨﺎﺒﻴﺏ ﻋﻨﺩ ﺩﺭﺠﺔ ﺤﺭﺍﺭﺓ 37ﻡ ﻟﻤﺩﺓ 24ﺴـﺎﻋﺔ ﻭﺘﺭﻙ ﺍﻨﺒﻭﺏ ﺩﻭﻥ ﺍﻀﺎﻓﺔ ﻤﺎﺩﺓ SDSﻜﺴـﻴﻁﺭﺓ .ﺒﻌـﺩ ﺫﻟـﻙ ﺍﺠﺭﻴﺕ ﺴﻠﺴﻠﺔ ﻤـﻥ ﺍﻟﺘﺨـﺎﻓﻴﻑ ﻟﺠﻤﻴـﻊ ﺍﻟﻤـﺯﺍﺭﻉ ﺍﻟﻤﻌﺎﻤﻠـﺔ ﻭﺍﻟﺴﻴﻁﺭﺓ ﻏﻴﺭ ﺍﻟﻤﻌﺎﻤﻠﺔ ﺤﻴﺙ ﺨﻔﻑ ﺍﻟﻤﺯﺭﻭﻉ ﺍﻟﻰ 10-6 ،10-5 ﻭ 10-7ﻭﻨﺸﺭ ﻤﻘﺩﺍﺭ 0.2ﻤﻠﻠﺘﺭ ﻋﻠﻰ ﻭﺴﻁ ﺍﻻﻜـﺎﺭ ﺍﻟﻤﻐـﺫﻱ ﺍﻟﺼﻠﺏ ﻭﺤﻀﻥ ﺒﺩﺭﺠﺔ ﺤﺭﺍﺭﺓ 37ﻡ ﻟﻤﺩﺓ 24ﺴﺎﻋﺔ ﺍﻭ ﺤﺘـﻰ ﻅﻬﻭﺭ ﻤﺴﺘﻌﻤﺭﺍﺕ ﺒﺸﻜل ﻭﺍﻀﺢ ﻭﺒﻌﺩﻫﺎ ﺘﻜﻤل ﺍﻟﺘﺠﺭﺒﺔ ﻜﻤﺎ ﻓﻲ ﻁﺭﻴﻘﺔ ﺍﻟﺘﺤﻴﻴﺩ ﺒﺎﺴﺘﺨﺩﺍﻡ ﺼﺒﻐﺔ ﺍﻟـ.Acridine orange ﺍﻟﻨﺘﺎﺌﺞ ﻭﺍﻟﻤﻨﺎﻗﺸﺔ ﻤﻥ ﻤﺠﻤﻭﻉ 150ﻋﻴﻨﺔ ﻤـﻥ ﻋﻴﻨـﺎﺕ ﺍﻟﺒـﻭل ﻟﻤﺭﻀـﻰ ﻤﺼﺎﺒﻴﻥ ﺒﺎﻟﺘﻬﺎﺒﺎﺕ ﺍﻟﻤﺠﺎﺭﻱ ﺍﻟﺒﻭﻟﻴﺔ ﻜﺎﻨﺕ 110ﻋﻴﻨﺔ ﻤﻭﺠﺒـﺔ ﻟﻅﻬﻭﺭ ﺍﻟﻨﻤﻭ ﺍﻟﺒﻜﺘﻴﺭﻱ ﻭﻤﻥ ﻫﺫﻩ ﺍﻟﻌﻴﻨﺎﺕ ﺘﻡ ﺍﻟﺤﺼﻭل ﻋﻠﻰ 23 ﻋﺯﻟﺔ ﻤﺤﻠﻴﺔ ﻟﻠﺠﻨﺱ Klebsiellaﺍﻱ ﺒﻨﺴﺒﺔ ﻋـﺯل ،%25.9 12ﻤﻨﻬﺎ ﺘﻌﻭﺩ ﺍﻟﻰ ﺍﻟﻨﻭﻉ Klebsiella pneumoniaeﻭﺒﻨﺴﺒﺔ ﻋﺯل ،%10.9ﺍﻋﺘﻤﺎﺩﹰﺍ ﻋﻠﻰ ﺍﻻﺨﺘﺒﺎﺭﺍﺕ ﺍﻟﺘﺸﺨﻴﺼﻴﺔ ﺍﻟﺨﺎﺼﺔ ﺒﻬﺫﻩ ﺍﻟﺠﺭﺜﻭﻤﺔ ] [٧ ،٦ﻜﻤﺎ ﺘﻡ ﺍﻟﺘﺄﻜﺩ ﻤﻥ ﺼـﺤﺔ ﺍﻟﺘﺸـﺨﻴﺹ ﺒﺎﺴﺘﺨﺩﺍﻡ ﻨﻅﺎﻡ ﺍﻟﺘﺸﺨﻴﺹ ).(API-20E ﺘﻡ ﺍﺠﺭﺍﺀ ﺍﺨﺘﺒﺎﺭ ﺍﻟﺤﺴﺎﺴﻴﺔ ﻟﻠﻌﺯﻻﺕ ﺍﻟﻤﺤﻠﻴﺔ ﻗﻴﺩ ﺍﻟﺩﺭﺍﺴﺔ ﻟﻌﺩﺩ ﻤﻥ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﺍﺫ ﻟﻭﺤﻅ ﻓﻲ ﺍﻻﺨﺘﺒﺎﺭ ﺍﻻﻭﻟﻲ ﻟﺤﺴﺎﺴﻴﺔ ﺍﻟﻌﺯﻻﺕ ﺍﻟﺠﺭﺜﻭﻤﻴﺔ ﻟـ 19ﻤﻀﺎﺩ ﺤﻴـﻭﻱ ﺍﻤﺘﻠﻜـﺕ ﺴـﺒﻌﺔ ﺍﻟﻤﺠﻠﺔ ﺍﻟﻌﺭﺍﻗﻴﺔ ﻟﻠﻌﻠﻭﻡ ،ﺍﻟﻤﺠﻠﺩ ،٥١ﺍﻟﻌﺩﺩ ،٢٠١٠ ،٣ﺍﻟﺼﻔﺤﺔ ٤٢١-٤١٥ ﻓﺭﺝ ﻭﻏﻨﻴﻤﺔ ﻋﺯﻻﺕ ﻤﻘﺎﻭﻤﺔ ﻤﺘﻌﺩﺩﺓ ﻟﻠﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ )Multi- (MDR ]،[13,12ﻜﻤﺎ ﻗﺩ ﻴﻌﻭﺩ ﺴﺒﺏ ﺍﻟﻤﻘﺎﻭﻤﺔ ﺍﻟﻌﺎﻟﻴﺔ ﻟﻬﺫﻩ ﺍﻟﻤﻀـﺎﺩﺍﺕ Resistant drugﺍﻱ ﺍﻨﻬﺎ ﻤﻘﺎﻭﻤﺔ ﻟﺜﻼﺙ ﻤﻀﺎﺩﺍﺕ ﺍﻭ ﺍﻜﺜـﺭ ﺍﻟﻰ ﺍﻥ ﻫﺫﻩ ﺍﻟﻌﺯﻻﺕ ﻏﺎﻟﺒﹰﺎ ﻤﺎ ﺘﻌﻭﺩ ﺍﻟـﻰ ﻤﺭﻀـﻰ ﺍﺴـﺘﻌﻤﻠﻭﺍ ﻭﻴﺘﻀﺢ ﻤﻥ ﺍﻟﺠﺩﻭل 2ﺍﻥ ﻫﻨﺎﻟـﻙ ﺍﺨﺘﻼﻓـﺎﺕ ﺒﺴـﻴﻁﺔ ﺒـﻴﻥ ﺍﻥ ﺘﻌﺩﺩ ﺍﻟﻤﻘﺎﻭﻤﺔ ﻟﻤﺠﺎﻤﻴﻊ ﻤﻔﻴﺩﺓ ﻤﻥ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﺘﺸﻤل ﺍﻟﻌﺯﻻﺕ ﻓﻲ ﻤﻘﺎﻭﻤﺘﻬﺎ ﻟﻠﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﻭﺍﻨﻬﺎ ﻤﻘﺎﻭﻤـﺔ ﺠـﺩﹰﺍ ﺍﻟﺒﺘﺎﻻﻜﺘﺎﻡ ،ﺍﻻﻤﻴﻨﻭﻜﻼﻴﻜﻭﺴﺎﻴﺩ ﻭﺍﻟﻜﻭﻴﻨﻭﻟـﻭﻨﺯ ﻗـﺩ ﺍﺯﺩﺍﺩ ﻓـﻲ ) (%100ﻟﻤﻀﺎﺩﺍﺕ ﺍﻻﻤﺒﻴﺴﻠﻴﻥ ،ﺒﺒﺭﺍﺴـﻴﻠﻴﻥ ،ﺍﻤﻭﻜﺴﻴﺴـﻴﻠﻴﻥ، ﺍﻟﺴﻨﻭﺍﺕ ﺍﻻﺨﻴﺭﺓ ﺒﺸﻜل ﻋﺎﻡ ﺒﻴﻥ ﻋﺩﺩ ﻤـﻥ ﺍﻟﺒﻜﺘﺭﻴـﺎ ﺍﻟﺴـﺎﻟﺒﺔ ﺒﻨﺴﻠﻴﻥ ﺝ ،ﺘﺘﺭﺍﺴﺎﻴﻜﻠﻴﻥ ،ﺍﺭﺜﺭﻭﻤﺎﻴﺴﻴﻥ ﻭﺠﻨﺘﺎﻤﺎﻴﺴﻴﻥ .ﻭﺍﻅﻬﺭﺕ ﻟﺼﺒﻐﺔ ﻜﺭﺍﻡ ﺨﺎﺼﺔ ﺒﻴﻥ ﺍﻟﻤﺭﻀﻰ ﺍﻟﺭﺍﻗﺩﻴﻥ ﻓﻲ ﺍﻟﻤﺴﺘﺸـﻔﻴﺎﺕ ﺍﻟﻌﺯﻻﺕ ﻤﻘﺎﻭﻤﺔ ﻋﺎﻟﻴﺔ ﻟﻤﻀﺎﺩﺍﺕ ﺴﻴﻔﺎﻟﻴﻜﺴـﻴﻥ ،ﺴـﻴﻔﺎﻟﻭﺜﻴﻥ، ] [14ﻭﻓﻲ ﺍﻟﺩﻭل ﺍﻟﻨﺎﻤﻴﺔ ﺘﻜﻭﻥ ﻤﻘﺎﻭﻤﺔ ﺍﻟﺒﻜﺘﺭﻴـﺎ ﻟﻠﻤﻀـﺎﺩﺍﺕ ﺴﻴﻔﺘﺎﺯﺩﻴﻡ ،ﺴﺒﺭﻭﻓﻠﻭﻜﺴﺎﺴﻴﻥ ،ﺴﺘﺭﺒﺘﻭﻤﺎﻴﺴﻴﻥ ﻭﺍﻟﺘﻭﺒﺭﺍﻤﺎﻴﺴـﻴﻥ ﻋﺎﻟﻴﺔ ﻭﻫﺫﺍ ﻤﺭﺘﺒﻁ ﺒﺎﻻﺴﺘﻌﻤﺎل ﻏﻴﺭ ﺍﻟﻤﻨﺎﺴﺏ ﻟﻬﺫﻩ ﺍﻟﻤﻀـﺎﺩﺍﺕ ـﻴﻔﺎﻜﻠﻭﺭ، ـﺎﺩﺍﺕ ﺴـ ـﻁﺔ ﻟﻤﻀـ ـﺔ ﻤﺘﻭﺴـ ) ،(%86–71ﻭﻤﻘﺎﻭﻤـ ﻭﻓﻘﺩﺍﻥ ﺍﻟﻌﻨﺎﻴﺔ ﺍﻟﺼﺤﻴﺔ ﺍﻟﺸﺨﺼﻴﺔ ﻭﺍﺴـﺘﻌﻤﺎل ﻋﻼﺠـﺎﺕ ﺫﺍﺕ ﺴﻴﻔﺭﺍﺩﻴﻥ ﻭﻨﺎﻟﺩﻜﺴﻙ ﺍﺴﻴﺩ ) ،(%57–43ﻓﻲ ﺤﻴﻥ ﺍﻨﻬﺎ ﺍﻅﻬﺭﺕ ﻨﻭﻋﻴﺔ ﺭﺩﻴﺌﺔ ﻭﻫﺫﺍ ﻤﺎ ﻴﺠﻌل ﻋﻤﻠﻴﺔ ﺍﻟﻌﻼﺝ ﺼﻌﺒﻪ ].[15 ﻤﻘﺎﻭﻤﺔ ﻀﻌﻴﻔﺔ ﻟﻤﻀﺎﺩ ﺴﻴﻔﻭﺘﺎﻜﺴﻴﻡ ) (%29ﻭﻜﺎﻨـﺕ ﺤﺴﺎﺴـﺔ ﺘﻅﻬﺭ ﺍﻟﺠﺭﺍﺜﻴﻡ ﺍﻟﻤﻨﺘﺠﺔ ﻻﻨﺯﻴﻤﺎﺕ ﺍﻟﺒﻴﺘﺎﻻﻜﺘﺎﻤﻴﺯ ﺤﺴﺎﺴﻴﺔ ﻟﺒﻌﺽ ﻟﻤﻀﺎﺩﺍﺕ ﻜﻠﻭﺭﺍﻤﻔﻨﻴﻜﻭل ﻭﺍﻻﻤﻴﻜﺎﺴﻴﻥ. ﺍﻟﻤﻀﺎﺩﺍﺕ ﻤﺜل ﺍﻻﻤﻴﻜﺎﺴﻴﻥ ] [16ﻜﻤﺎ ﻟﻭﺤﻅ ﺍﻥ ﻤﻌﻅﻡ ﻋﺯﻻﺕ ﻤﻥ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﻤﺴﺘﺨﺩﻤﺔ ﻭﻜﻤﺎ ﻤﻭﻀﺢ ﻓﻲ ﺍﻟﺠﺩﻭل .2 ﺟﺪول :2اﺧﺘﺒﺎر اﻟﺤﺴﺎﺳﻴﺔ ﻟﻠﻤﻀﺎدات اﻟﺤﻴﻮﻳﺔ ﻟﻌﺰﻻت [11] . K.pneumoniae ﻋﺩﺩ ﻋﺯﻻﺕ K. pneumoniae ﺍﻟﻨﺴﺒﺔ ﺕ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 :R ﺍﻟﻤﻀﺎﺩ ﺍﻟﺤﻴﻭﻱ K7 K6 K5 K4 K3 K2 K1 R Ampicillin R Pepracillin R Amoxicillin R Penicillin G R Cephalexin I Cephalothin S Cefaclor S Cephradine S Cefotaxime S Ceftazidine R Ciprofloxacin R Tetracyilin S Chloramphenicol R Erythromycin R Gentamycin R Streptomycin I Tobramycin R Nalidixic acid S Amikacin :Sﺤﺴﺎﺴﺔ ﻤﻘﺎﻭﻤﺔ R R R R R R R R R R R R R I R R R R R R R R R R R R I R R R R R I R R R S S S R R R R R R I R R R R R R R S S S S :Iﻤﺘﻭﺴﻁ R R R R R R R R R R R R I R R R I R I R I S I R S I I I R R I R R R R R S I S R R R R R R R R R R R R I S S S S S ﺍﻟﺤﺴﺎﺴﻴﺔ ﺍﻟﻤﺌﻭﻴﺔ ﻟﻠﻌﺯﻻﺕ ﺍﻟﻤﻘﺎﻭﻤﺔ 100% 100% 100% 100% 71% 71% 57% 57% 29% 71% 71% 100% 100% 100% 86% 86% 43% - ﺍﻟﻌﺩﻴﺩ ﻤﻥ ﺍﻟﻤﻀﺎﺩﺍﺕ ﻭﻟﻤﺩﺓ ﺯﻤﻨﻴﻪ ﻁﻭﻴﻠﺔ ] .[12ﻤﻥ ﺍﻟﻭﺍﻀـﺢ K. pneumoniaeﺍﻟﻤﻨﺘﺠـﺔ ﻟﻠــ ESBLﻜﺎﻨـﺕ ﻤﻘﺎﻭﻤـﺔ ﻟﻠﺠﻨﺘﺎﻤﺎﻴﺴﻴﻥ ﻭﺍﻟﺘﺘﺭﺍﺴﺎﻴﻜﻠﻴﻥ ﻭﻟﻜﻨﻬـﺎ ﺤﺴﺎﺴـﺔ ﻟﻠﺴﻴﻔﻭﻜﺴـﻴﺘﻴﻥ ﻭﺍﻻﻤﻴﻜﺎﺴﻴﻥ ] .[17ﻭﺍﻟﺤﺴﺎﺴﻴﺔ ﺍﻟﺘﻲ ﺍﻅﻬﺭﺘﻬﺎ ﺍﻟﻌﺯﻻﺕ ﺍﻟﻤﺤﻠﻴﺔ ﻟﻠﻜﻠﻭﺭﺍﻤﻔﻨﻴﻜﻭل ﻗﺩ ﻴﻌﻭﺩ ﺍﻟﻰ ﻗﻠﺔ ﺍﺴﺘﺨﺩﺍﻡ ﻫﺫﺍ ﺍﻟﻤﻀﺎﺩ ﻟﻌـﻼﺝ ﺍﺼﺎﺒﺎﺕ ﺍﻟـ .[18] UTI ﺘﻡ ﺍﺠﺭﺍﺀ ﺘﺠﺭﺒـﺔ ﺍﻟﺘﺤﻴﻴـﺩ ﻟﻠﺒﻼﺯﻤﻴـﺩﺍﺕ ﺒﺎﺴـﺘﺨﺩﺍﻡ ﺍﻟــ Acridine orangeﻭﺍﻟـ SDSﻋﻠﻰ ﺠﻤﻴـﻊ ﻋـﺯﻻﺕ K. pneumoniaeﻭﺍﺨﺘﺒﺎﺭ ﺤﺴﺎﺴﻴﺔ ﺍﻟﺒﻜﺘﺭﻴﺎ ﺘﺠﺎﻩ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺘﻲ ﺍﻅﻬﺭﺕ ﻟﻬﺎ ﻤﻘﺎﻭﻤﺔ ﻋﺎﻟﻴﺔ ﻭﻜﻤﺎ ﻫﻭ ﻤﻭﻀﺢ ﻤﻥ ﺍﻟﺠـﺩﻭﻟﻴﻥ 3 ﻭ.4 ﺠﺩﻭل :3ﺘﺄﺜﻴﺭ ﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩ ﻟﻌﺯﻻﺕ K. pneumoniae ﺒﺎﺴﺘﺨﺩﺍﻡ Acridine orangeﻓﻲ ﻤﻘﺎﻭﻤﺔ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ. ﺍﻟﻨﺴﺒﺔ ﺍﻟﻤﺌﻭﻴﺔ ﻟﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩ ﺍﻟﺫﻱ ﺕ 1 ﻴﺸﻔﺭ ﻟﻤﻘﺎﻭﻤﺔ ﺍﻟﻤﻀﺎﺩ )(% ﺍﻟﻤﻀﺎﺩ ﺍﻟﺤﻴﺎﺘﻲ ﺭﻗﻡ ﻋﺯﻟﺔ K. pneumoniae K7 K6 K5 K4 K3 K2 K1 R R R R R R 10 Ampicillin 2 Pepracillin 66 45 79 80 42 85 50 92 94 90 85 3 Amoxicillin S S 4 Penicillin G S 89 93 95 90 5 Cephalexin 78 80 I S S 67 81 60 95 I ﺍﻥ ﺍﻟﻤﻘﺎﻭﻤﺔ ﺍﻟﻌﺎﻟﻴﺔ ﺍﻟﺘﻲ ﺍﻅﻬﺭﺘﻬﺎ ﺒﻜﺘﺭﻴـﺎ K. pneumoniae 6 Cephalothin I 70 69 28 40 ﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺒﻴﺘﺎﻻﻜﺘﺎﻡ ﺘﻌﻭﺩ ﺒﺸﻜل ﻜﺒﻴﺭ ﺍﻟﻰ ﺍﻨﺘﺎﺠﻬﺎ ﻻﻨﺯﻴﻤـﺎﺕ 7 Ceftazidine S 75 90 71 80 81 I R Ciprofloxacin 8 R I ﺍﻟﺒﺘﺎﻻﻜﺘﺎﻤﻴﺯ ﻭﺍﺴﻌﺔ ﺍﻟﻁﻴﻑ – Extended Spectrum Beta )(ESBL Lactamaseﺍﺫ ﺍﺸﺎﺭﺕ ﺍﻟﻌﺩﻴﺩ ﻤﻥ ﺍﻟﺩﺭﺍﺴﺎﺕ ﺍﻟﻰ ﺍﻥ ﺍﻨﻭﺍﻉ ﺍﻟـ Klebsiellaﻤﻨﺘﺠﺔ ﺒﺸﻜل ﻜﺒﻴﺭ ﻟﻬﺫﻩ ﺍﻻﻨﺯﻴﻤﺎﺕ 9 Tetracyilin I R R R I 77 S 85 66 88 83 87 90 R Erythromycin 10 R R R R R R 86 84 69 79 72 91 70 Gentamycin 11 ﺍﻟﻤﺠﻠﺔ ﺍﻟﻌﺭﺍﻗﻴﺔ ﻟﻠﻌﻠﻭﻡ ،ﺍﻟﻤﺠﻠﺩ ،٥١ﺍﻟﻌﺩﺩ ،٢٠١٠ ،٣ﺍﻟﺼﻔﺤﺔ ٤٢١-٤١٥ ﻓﺭﺝ ﻭﻏﻨﻴﻤﺔ R Streptomycin 12 Tobramycin 13 R ﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩﺍﺕ ﻓﻲ ﺒﻜﺘﺭﻴﺎ ﺍﻟـ K. pneumoniaeﺒﺘـﺭﺩﺩ 89 85 84 76 93 65 ﻋﺎﻟﻲ ﻤﻘﺎﺭﻨـﺔ ﺒﺒﻘﻴـﺔ ﻋﻭﺍﻤـل ﺍﻟﺘﺤﻴﻴـﺩ ﺍﻟﻤﺴـﺘﺨﺩﻤﺔ ﻜﺎﻟــ R I R I R R :Rﻤﻘﺎﻭﻤﺔ. :Sﺤﺴﺎﺴﺔ )ﺘﺸﻴﺭ ﺍﻟﻰ ﺍﻥ ﺍﻟﻨﺴﺒﺔ ﺍﻟﻤﺌﻭﻴﺔ ﻟﻠﺘﺤﻴﻴﺩ .(%100 :Iﻤﺘﻭﺴﻁﺔ ﺍﻟﺤﺴﺎﺴﻴﺔ )ﻟﻡ ﻴﺠﺭ ﺍﺨﺘﺒﺎﺭﻫﺎ(. ﺠﺩﻭل :4ﺘﺄﺜﻴﺭ ﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩ ﻟﻌﺯﻻﺕ K. pneumoniae ﺒﺎﺴﺘﺨﺩﺍﻡ ﺍﻟـ SDSﻓﻲ ﻤﻘﺎﻭﻤﺔ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﺍﻟﻨﺴﺒﺔ ﺍﻟﻤﺌﻭﻴﺔ ﻟﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩ ﺍﻟﺫﻱ ﺕ ﺍﻟﻤﻀﺎﺩ ﺍﻟﺤﻴﻭﻱ ﻴﺸﻔﺭ ﻟﻤﻘﺎﻭﻤﺔ ﺍﻟﻤﻀﺎﺩ )(% K7 K6 K5 K4 K3 K2 K1 R 1 Ampicillin R R R R 2 Pepracillin 89 82 98 S 87 88 85 3 Amoxicillin S S S 4 Penicillin G 96 S 99 94 92 5 Cephalexin 80 91 6 Cephalothin I 7 Ceftazidine I R 98 91 92 94 ] [20ﻭﻫﺫﻩ ﺍﻟﺒﻜﺘﺭﻴﺎ ﺍﻟﻤﻨﺘﺠﺔ ﻟﻬﺫﻩ ﺍﻻﻨﺯﻴﻤﺎﺕ ﻋﺎﺩﺓ ﻤـﺎ ﺘﻜـﻭﻥ ﺒﻼﺯﻤﻴﺩﺍﺘﻬﺎ ﺘﺤﻭﻱ ﻤﻭﺭﺜﺎﺕ ﺘﺸﻔﺭ ﺍﻴﻀﹰﺎ ﻟﻤﻘﺎﻭﻤـﺔ ﻤﻀـﺎﺩﺍﺕ ﻭﺍﻟﺘﺘﺭﺍﺴﺎﻴﻜﻠﻴﻥ ] ،[21ﻜﻤﺎ ﻻﺤﻅ ﻋﺩﺩ ﻤﻥ ﺍﻟﺒﺎﺤﺜﻴﻥ ﺍﻥ ﺠﻤﻴـﻊ ـﺯﻻﺕ ﻋـــــــــــــــــــــــــــ K.pneumoniaeﺍﻟﻤﻌﺯﻭﻟﺔ ﻤﻥ ﺍﺼﺎﺒﺎﺕ ﺍﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺘﺤـﻭﻱ ﺒﻼﺯﻤﻴﺩ ) (87kbﻭﺍﻥ ﻤﻘﺎﻭﻤﺔ ﺍﻟﺒﺘﺎﻻﻜﺘﺎﻡ ﻭﺍﻻﻤﻴﻨﻭﻜﻼﻴﻜﻭﺴـﺎﻴﺩ ﻭﺍﻟﺘﺘﺭﺍﺴﺎﻴﻜﻠﻴﻥ ﺘﻔﻘﺩ ﺒﻌﺩ ﺘﺤﻴﻴﺩ ﺍﻟﺒﻼﺯﻤﻴﺩﺍﺕ ﻋﻥ ﻁﺭﻴﻕ ﺍﻟﻤﻌﺎﻤﻠﺔ 87 89 83 I ﺒﺎﻟـ Acridine orangeﻤﻤﺎ ﻴﺩل ﻋﻠﻰ ﺍﻥ ﻤﻭﺭﺜﺎﺘﻬﺎ ﻤﺤﻤﻭﻟـﺔ 92 ﻋﻠﻰ ﺍﻟﺒﻼﺯﻤﻴﺩ ] .[17ﻭﻭﺠـﺩ ﺍﻥ ﺍﻟﻌﺩﻴـﺩ ﻤـﻥ ﺒﻜﺘﺭﻴـﺎ K. 90 87 75 70 I S S R Ciprofloxacin 8 I R 15 R R I S S 92 86 85 82 S R Erythromycin 10 R R R R R 85 Gentamycin 11 S 86 91 90 S 95 R Streptomycin 12 R R R R R I 91 S 92 90 86 S Tobramycin 13 ﺍﻟﺒﻼﺯﻤﻴﺩﺍﺕ Rﻋﻥ ﻁﺭﻴﻕ ﺍﻨﺘﺎﺠﻬﺎ ﻻﻨﺯﻴﻤـﺎﺕ ﺍﻟﺒﺘﺎﻻﻜﺘـﺎﻤﻴﺯ S 90 86 89 92 9 ﺍﻟﺒﻴﺘﺎﻻﻜﺘﺎﻡ ﺍﻟﻰ ﺍﻥ ﺼﻔﺔ ﻤﻘﺎﻭﻤﺔ ﻫﺫﻩ ﺍﻟﻤﻀﺎﺩﺍﺕ ﻤﺤﻤﻭﻟﺔ ﻋﻠـﻰ S I Tetracyilin ﻴﻌﻭﺩ ﺤﺩﻭﺙ ﺍﻟﺘﺤﻴﻴﺩ ﻓﻲ ﻤﻘﺎﻭﻤﺔ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴﺔ ﻟﻤﺠﻤﻭﻋـﺔ ـﻭﺒﺭﻴﻡ ـﻭﻨﺯ ،ﺍﻟﺘﺭﺍﻤﻴﺜـ ـﺎﻴﺩ ،ﺍﻟﻜﻭﻴﻨﻭﻟـ ﺍﺨ ـﺭﻯ ﻜﺎﻷﻤﻴﻨﻭﻜﻼﻴﻜﻭﺴـ ﺭﻗﻡ ﻋﺯﻟﺔ K. pneumoniae R ـ Novobiocinﻭﺍﻟـ.[19] Ethidium bromide R I :Rﻤﻘﺎﻭﻤﺔ. :Sﺤﺴﺎﺴﺔ )ﺘﺸﻴﺭ ﺍﻟﻰ ﺍﻥ ﺍﻟﻨﺴﺒﺔ ﺍﻟﻤﺌﻭﻴﺔ ﻟﻠﺘﺤﻴﻴﺩ.(% 100 :Iﻤﺘﻭﺴﻁﺔ ﺍﻟﺤﺴﺎﺴﻴﺔ )ﻟﻡ ﻴﺠﺭ ﺍﺨﺘﺒﺎﺭﻫﺎ(. ﻴﺘﻀﺢ ﻤﻥ ﺍﻟﺠﺩﻭﻟﻴﻥ 3ﻭ 4ﺍﻥ ﺍﺴﺘﺨﺩﺍﻡ ﺍﻟــ Acridine orangeﻭﺍﻟـ SDSﺍﺩﻯ ﺍﻟﻰ ﺤﺩﻭﺙ ﺘﺤﻴﻴـﺩ ﻓـﻲ ﻤﻘﺎﻭﻤـﺔ ﺍﻟﻌــﺯﻻﺕ ﺍﻟﺒﻜﺘﻴﺭﻴــﺔ ﻟﻠﻤﻀــﺎﺩﺍﺕ ﺍﻟﺤﻴﻭﻴــﺔ ﺒﺒﺭﺍﺴــﻴﻠﻴﻥ، ﺍﻤﻭﻜﺴﻴﺴﻴﻠﻴﻥ ،ﺒﻨﺴﻠﻴﻥ ﺝ ،ﺴﻴﻔﺎﻟﻴﻜﺴﻴﻥ ،ﺴﻴﻔﺎﻟﻭﺜﻴﻥ ،ﺴـﻴﻔﺘﺎﺯﺩﻴﻡ، ﺘﺘﺭﺍﺴﺎﻴﻜﻠﻴﻥ ،ﺠﻨﺘﺎﻤﺎﻴﺴﻴﻥ ،ﻭﺘﻭﺒﺭﺍﻤﺎﻴﺴﻴﻥ ﻓﻲ ﺤﻴﻥ ﻟـﻡ ﻴﺤـﺩﺙ ﺘﺤﻴﻴﺩ ﻟﻤﻘﺎﻭﻤـﺔ ﺍﻟﻤﻀـﺎﺩﺍﺕ ﺍﻤﺒﻴﺴـﻴﻠﻴﻥ ،ﺴﺒﺭﻭﻓﻠﻭﻜﺴﺎﺴـﻴﻥ، ﺍﺭﺜﺭﻭﻤﺎﻴﺴﻴﻥ ﻭﺴﺘﺭﺒﺘﻭﻤﺎﻴﺴﻴﻥ .ﻭﻴﻼﺤﻅ ﻭﺠﻭﺩ ﺘﺸﺎﺒﻪ ﻓﻲ ﻓﻘﺩﺍﻥ ﺍﻟﻤﻘﺎﻭﻤﺔ ﻟﻠﻤﻀﺎﺩﺍﺕ ﺒﺎﺴﺘﺨﺩﺍﻡ ﻋﺎﻤﻠﻲ ﺍﻟﺘﺤﻴﻴﺩ ﺍﻻ ﺍﻥ ﻤﺎﺩﺓ ﺍﻟــ SDSﺍﻜﺜﺭ ﻜﻔﺎﺀﺓ ﻓﻲ ﺍﺤﺩﺍﺙ ﺍﻟﺘﺤﻴﻴﺩ ﻤﻥ ﻤﺎﺩﺓ ﺍﻟـ Acridine orangeﺤﻴﺙ ﺍﻅﻬﺭﺕ ﺍﻟﻨﺘﺎﺌﺞ ﻓﻘـﺩﺍﻥ ﺍﻟﻤﻘﺎﻭﻤـﺔ ﻟﻠﻤﻀـﺎﺩﺍﺕ pneumoniaeﺍﻟﻤﻌﺯﻭﻟﺔ ﻤﻥ ﻋﻴﻨﺎﺕ ﺍﻟﺒﻭل ﺍﻅﻬﺭﺕ ﺍﺴـﺘﺠﺎﺒﺔ ﻗﻠﻴﻠﺔ ﻟﻤﻀﺎﺩ ﺍﻟﺴﻴﻔﻭﺘﺎﻜﺴﻴﻡ ﻭﻫﺫﻩ ﺍﻟﻌﺯﻻﺕ ﺘﺤﻤل ﺒﻼﺯﻤﻴﺩ ﻴﺸﻔﺭ ﻟﻤﻘﺎﻭﻤﺔ ﺍﻟﺘﺘﺭﺍﺴﺎﻴﻜﻠﻴﻥ ﻭﺍﻟﺴﻴﻔﻭﻜﺴﻴﺘﻴﻥ ] .[22ﺍﻥ ﻋﺩﻡ ﺤـﺩﻭﺙ ﺍﻟﺘﺤﻴﻴﺩ ﻟﻤﻘﺎﻭﻤﺔ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻤﺒﻴﺴﻠﻴﻥ ﻭﺴﺘﺭﺒﺘﻭﻤﺎﻴﺴﻴﻥ ﺠﺎﺀ ﻤﺘﻔﻘﹰﺎ ﻤﻊ ﻤﺎ ﺘﻭﺼل ﺍﻟﻴﻪ ﺒﻌﺽ ﺍﻟﺒﺎﺤﺜﻴﻥ ﻓـﻲ ﺍﺤـﺩﻯ ﺍﻟﻤﺴﺘﺸـﻔﻴﺎﺕ ﺍﻟﺒﺎﻜﺴﺘﺎﻨﻴﺔ ﻤﻥ ﺍﻥ ﺼﻔﺔ ﻤﻘﺎﻭﻤﺔ ﻫﺫﻩ ﺍﻟﻤﻀﺎﺩﺍﺕ ﻓـﻲ ﺒﻜﺘﺭﻴـﺎ K. pneumoniaeﺍﻟﻤﻌﺯﻭﻟﺔ ﻤﻥ ﻋﻴﻨﺎﺕ ﻤﺨﺘﻠﻔـﺔ ﻟﻤﺭﻀـﻰ ﺭﺍﻗﺩﻴﻥ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺘﻜﻭﻥ ﻤﺤﻤﻭﻟﺔ ﻋﻠﻰ ﺍﻟﻜﺭﻭﻤﻭﺴﻭﻡ ﻭﻟـﻴﺱ ﺍﻟﺒﻼﺯﻤﻴﺩ ﻭﺫﻟﻙ ﺒﻌﺩ ﺍﺠﺭﺍﺀ ﺍﻟﺘﺤﻴﻴﺩ ﺒﺎﺴﺘﺨﺩﺍﻡ ﺍﻟــ Acridine .[23] orange ﺘﺸﻴﺭ ﺍﻟﻨﺘﺎﺌﺞ ﺍﻟﺘﻲ ﺤﺼﻠﻨﺎ ﻋﻠﻴﻬﺎ ﺍﻟﻰ ﻋﺩﻡ ﺤﺩﻭﺙ ﺘﺤﻴﻴﺩ ﻟﻤﻘﺎﻭﻤﺔ ﺍﻟﺴﺒﺭﻭﻓﻠﻭﻜﺴﺎﺴﻴﻥ ﻓﻲ ﺤﻴﻥ ﺍﺸﺎﺭﺕ ﺩﺭﺍﺴﺎﺕ ﺍﻟـﻰ ﺍﻥ ﺒﻜﺘﺭﻴـﺎ K. pneumoniaeﺘﺤﻭﻱ ﺒﻼﺯﻤﻴﺩﺍﺕ ﻓﻴﻬﺎ ﻤﻭﺭﺜﺎﺕ ﻤﺴـﺅﻭﻟﺔ ﻋﻥ ﺍﻟﺘﺸﻔﻴﺭ ﻟﻤﻘﺎﻭﻤﺔ ﻤﻀﺎﺩﺍﺕ ﺍﻟﻜﻭﻴﻨﻭﻟﻭﻨﺯ ﻜﻤﺎ ﻟﻭﺤﻅ ﻫﺫﺍ ﻓـﻲ ﺍﻟﻭﻻﻴﺎﺕ ﺍﻟﻤﺘﺤﺩﺓ ﺍﻻﻤﺭﻴﻜﻴﺔ ] ،[24ﻭﺫﻜﺭ ﻭﺠﻭﺩ ﺍﺭﺘﺒﺎﻁ ﻗﺭﻴـﺏ ﺒﻴﻥ ﺍﻨﺘﺎﺝ ﺍﻨﺯﻴﻤﺎﺕ ESBLﻭﻤﻘﺎﻭﻤﺔ ﺍﻟﺴﺒﺭﻭﻓﻠﻭﻜﺴﺎﺴـﻴﻥ ﻓـﻲ ﺍﻟﻌﺩﻴﺩ ﻤﻥ ﺴﻼﻻﺕ ﺍﻟـ ،[25] K. pneumoniaeﺍﻤﺎ ﺒﺎﻟﻨﺴﺒﺔ ﻟﻠﻤﻀﺎﺩ ﺍﺭﺜﺭﻭﻤﺎﻴﺴﻴﻥ ﻓﺎﻥ ﻋﺩﻡ ﺤﺩﻭﺙ ﺘﺤﻴﻴﺩ ﻟﻤﻘﺎﻭﻤﺘﻪ ﻗﺩ ﻴﻌﺯﻯ ﺍﻟﻰ ﻭﺠﻭﺩ ﺍﻟﺼﻔﺔ ﺍﻟﻤﺴﺅﻭﻟﺔ ﻋﻥ ﻤﻘﺎﻭﻤﺘﻪ ﻋﻠﻰ ﻨﻭﻉ ﺍﺨﺭ ﻤـﻥ ﺒﺎﻟﻨﺴﺒﺔ ﻟﻠـ SDSﻜﺎﻨﺕ ﺒﻤﺩﻯ %100 –70ﺍﻤﺎ ﺒﺎﻟﻨﺴﺒﺔ ﻟﻌﺎﻤل ﺍﻟﺒﻼﺯﻤﻴﺩﺍﺕ ﻏﻴﺭ ﺍﻟﻨﻭﻉ .R ﺍﻻﻜﺭﺩﻴﻥ ﻓﻜﺎﻨﺕ ،%100 – 28ﻭﺘﺘﻔﻕ ﻫﺫﻩ ﺍﻟﻨﺘﻴﺠﺔ ﻤـﻊ ﻤـﺎ ﺍﻟﻤﺼﺎﺩﺭ ﺍﺸﺎﺭ ﻟﻪ ﺍﻟﺒﺎﺤﺜﻭﻥ ﻓﻲ ﺩﻭﺭ ﺍﻟـ SDSﻜﻤﺎﺩﺓ ﺍﻜﺜﺭ ﺘـﺄﺜﻴﺭﹰﺍ ﻓـﻲ ٤٢١-٤١٥ ﺍﻟﺼﻔﺤﺔ،٢٠١٠ ،٣ ﺍﻟﻌﺩﺩ،٥١ ﺍﻟﻤﺠﻠﺩ،ﺍﻟﻤﺠﻠﺔ ﺍﻟﻌﺭﺍﻗﻴﺔ ﻟﻠﻌﻠﻭﻡ 12. 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