공중보건에 부담이 되는 Clostridium difficile 지역사회 감염의 증가
Increase of Clostridium difficile in Community; Another Worrisome Burden for Public Health
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배경: 유럽과 북미를 중심으로 지역사회 Clostridium difficile 감염의 증가가 보고되고 있지만, 국내 보고는 아직 충분치 않은 실정이다. 최근의 지역사회 CDI 현황에 대한 자료는 의료기관 내 감염으로 알려져 왔던 CDI의 지역사회로의 확산과 감염관리 필요성에 대한 근거가 될 수 있다. 방법: 2012년부터 2014년까지 국민건강보험공단 일산병원에서 분리된 C. difficile 균주를 대상으로 하였다. 임상적인 특징, 지역사회 또는 의료기관에서 감염, 의료기관 관련 인자 및 이전 항균제 사용력 등은 전산화된 의무기록을 검토하였다. 설사변이나 비고형변에서만 C. difficile 배양을 실시하였다. 독소 생성 여부는 일차적으로 효소형광 면역측정법으로 검사하였고, 추가로 57 검체에서 toxin B와 binary toxin 생성 여부를 PCR로 확인하였다. CDI는 비고형변에서 독소 생성 C. difficile의 분리로 정의하였다. 결과: 지난 3년간 의뢰된 C. difficile배양은 중복 의뢰를 제외하고 2,190건이었고, 배양 양성이 251건(11.5%, 251/2,190)이었다. 배양 양성인 경우 healthcare facility-associated hospital onset (HCFA-HO)군에서 168건(66.9%, 168/251), healthcare facility-associated community onset (HCFA-CO)군에서 45건(17.9%, 45/251), community-associated (CA)군에서 38건(15.1%, 38/251)이 분리되었다. 연도별 분리율을 살펴보면 2012년 11.3% (78/689), 2013년 9.6% (68/712), 2014년 13.3% (105/789)이며, HCFA-CO군과 CA군을 모두 포함하는 지역사회 분리 건수는 2012년 25건(HCFA-CO군 16건과 CA군 9건)에서 2014년 35건(HCFA-CO군 16건과 CA군 19건)으로, 분리건수에서 CA군이 차지하는 비율이 2012년 11.5%에서 2014년도에는 18.1%로 증가하였다. 형광효소 면역검사법으로 독소 A와 B를 검출한 결과, HCFA-HO군 50.6% (84/166), HCFA-CO군 41.9% (18/43) 및 CA군 42.1% (16/38)의 양성률을 보여 3군 간에 큰 차이는 없었다. 총 57주에서 추가로 PCR로 tcdB 독소 유전자를 검출하였는데 HCFA-HO군 62.9% (22/35), HCFA-CO군 69.2% (9/13), CA군 100% (9/9)로 독소 검사법에 따른 차이를 보였다. 좀 더 심각한 임상증상과 관련된 binary toxin (cdtA/cdtB) 유전자는 57주 모두 검출되지 않았다. 결론: 고양지역에서 지역사회 CDI는 드물지 않으며, 특히 검사법에 따라 실제보다 적게 검출될 수 있으므로 주의가 필요하다. 지역사회에서 CDI의 확산은 공중보건에 새로운 부담이 될 수 있으므로 관심을 기울여야 하겠다.
Abstract
Background: Increasing rates of Clostridium difficile infection (CDI) have been reported mainly in Europe and North America; however, only limited reports have originated in Korea. The current epidemiology of CDI in the community could help to understand the outpatient healthcare environment and to extend infection control measures to outpatient settings. Methods: C. difficile isolates in NHIS Ilsan Hospital from 2012 to 2014 were included in this study. Clinical characteristics, acquisition types, and previous antimicrobial therapy were obtained via Electronic Medical Records. C. difficile culture was performed only in unformed stool. Toxin was positive by enzyme-linked fluorescent immunoassay (ELFA) in 247 specimens. In addition, toxin B and binary toxin gene were detected by PCR in 57 specimens. CDI was defined by toxigenic C. difficile isolation in unformed stool. Results: In the previous 3 years, 251 unduplicated C. difficile cases have been detected; 168 healthcare facility-associated hospital onset (HCFA-HO), 45 healthcare facility-associated community onset (HCFA-CO), and 38 community-associated (CA). Toxin positive rates by ELFA for toxin A&B were HCFA-HO 50.6% (84/166), HCFA-CO 41.9% (18/43), and CA 42.1% (16/38). Toxin positive rate by PCR for tcdB were HCFA-HO 62.9% (22/35), HCFA-CO 69.2% (9/13), and CA 100% (9/9). No binary toxin (cdtA/cdtB) was detected in 57 cases. Conclusion: Community-associated CDI may be underestimated in Goyang province, Korea, especially by commonly used ELFA toxin assay. The spread of community-associated CDI should be recognized as an increasing burden of public health.
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