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Zakażenie pałeczką ropy błękitnej a leczenie ran

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Pałeczka ropy błękitnej jest niezwykle oporną bakterią, która często doprowadza do zakażeń szpitalnych. Ze względu na mechanizmy chroniące ją przed antybiotykami stanowi poważny problem w procesie gojenia się ran. Szczególnie narażone na infekcję wywołaną tym patogenem są osoby z obniżoną odpornością.

Pałeczka ropy błękitnej (Pseudomonas aeruginosa) jest powszechnie występującą bakterią wywołującą zakażenia endogenne, wtórnie endogenne i egzogenne. Szczególnie szybko namnaża się w wilgotnym środowisku (np. w ranach, drogach oddechowych, drogach moczowych), przez co często wywołuje zakażenia szpitalne.

Pałeczka ropy błękitnej najczęściej wywołuje zakażenia ran oparzeniowych, pooperacyjnych oraz odleżyn. Wśród pacjentów szpitalnych na kontakt z pałeczką ropy błękitnej najbardziej narażone są osoby znajdujące się na oddziałach chirurgicznych, oparzeniowych, intensywnej terapii i hematologicznych. Czynnikami zwiększającymi ryzyko zakażenia P. aeruginosa są między innymi: przedłużająca się hospitalizacja, cukrzyca i obniżona odporność.

Brak podjęcia leczenia zakażenia miejscowego wywołanego przez pałeczki ropy błękitnej prowadzić może do pojawienia się zmian martwiczych oraz sepsy, stanowiącej realne zagrożenie dla życia chorego. W przypadku postępującej martwicy tkanek niezbędna może być np. amputacja kończyny lub jej fragmentu. Problem ten dotyczy szczególnie pacjentów z zespołem stopy cukrzycowej.

Lekooporność pałeczki ropy błękitnej

Pałeczka ropy błękitnej należy do bakterii Gram-ujemnych zdolnych do tworzenia biofilmu. Jest to struktura bakteryjna, chroniąca patogeny przed czynnikami zewnętrznymi oraz lekami.

Dodatkowo bakterie Pseudomonas aeruginosa pochodzenia szpitalnego często wykazują wielolekooporność, co stanowi poważne utrudnienie w leczeniu zakażenia. Wpływ na to ma zarówno oporność naturalna bakterii, jak i oporność nabyta. Zakażenie szczepami lekoopornymi prowadzi do rozwoju długotrwałego stanu zapalnego, który znacząco spowalnia proces gojenia rany.

Oporność naturalna P. aeruginosa wynika z niskiej przepuszczalności błony zewnętrznej bakterii oraz aktywnego usuwania z komórki antybiotyków i enzymów modyfikujących działanie leków. Bakterie są też zdolne do uodpornienia się na dany lek już w trakcie trwania terapii. Oporność nabyta powstaje w wyniku spontanicznych mutacji w DNA patogenu lub transferu genów pomiędzy komórkami, które odpowiadają za oporność na dany antybiotyk.

W ostatnich latach naukowcom udało się opisać gen P. aeruginosa o nazwie ReTS, który w swojej aktywnej formie hamuje geny odpowiedzialne za tworzenie biofilmu. Niestety odpowiada on też za kontrolowanie genów związanych ze zdolnością bakterii do przemieszczania się i produkcji toksyn, co stymuluje powstawanie ostrych stanów zapalnych.

Leczenie zakażeń pałeczką ropy błękitnej

Procedury stosowane przy leczeniu zakażonych ran trudno gojących się określają systemy TIMERS i MOIST. Obejmują one działania takie jak oczyszczanie tkanek, likwidacja stanu zapalnego, utrzymanie wilgotności w ranie, wsparcie regeneracji tkanek i wsparcie społeczne. W leczeniu ran zakażonych niezwykle ważne jest, aby rana była przemywana i oczyszczana przy każdej zmianie opatrunku. Do przemywania rany stosuje się antyseptyki oraz płyny obojętne dla tkanek np. sól fizjologiczną. Przy oczyszczaniu rany korzysta się z narzędzi (skalpel, łyżeczka), gazy, ultradźwięków, opatrunków o działaniu antybakteryjnym i przeciwbiofilmowym, żeli wodnych i preparatów enzymatycznych.

Antybiotyki w leczeniu zakażenia pałeczką ropy błękitnej

W wypadku przejścia zakażenia P. aeruginosa w infekcję uogólnioną wdrażana jest antybiotykoterapia. Najczęściej stosowanymi antybiotykami w leczeniu zakażenia pałeczką ropy błękitnej, bez uwzględniania nabytych mechanizmów oporności, są ureidopenicyliny wraz z inhibitoramiβ-laktamaz, cefalosporyny III lub IV generacji, karbapenemy, aztreonam, fluorochinolony, aminoglikozydy, polimyksyny. W przypadku wykrycia mechanizmów oporności bakterii na stosowane leczenie niezbędna jest jak najszybsza zmiana terapii. Ze względu na rozwój oporności nabytej wśród pałeczek ropy błękitnej opracowywane są nowe sposoby na zwalczanie zakażeń wywoływanych przez szczepy tej bakterii.

Jedna z obiecujących terapii wykorzystuje bakteriofagi, czyli wirusy niszczące bakterie. Leczenie to w Polsce wciąż jest uznawane za eksperymentalne, ale stosowane jest w przypadkach nieskuteczności antybiotykoterapii. Bakteriofagi posiadają silne właściwości bakteriobójcze oraz immunomodulujące przeciwko bakteriom Gram-dodatnim i Gram-ujemnym. Fagoterapia stanowi obecnie w Polsce alternatywę dla antybiotykoterapii w opornych zakażeniach ran oparzeniowych wywołanych przez P. aeruginosa.

Więcej tematów związanych z zakażeniami będzie poruszanych na konferencji II Forum Zakażeń, która odbędzie się w dniach 12-14 maja w Jachrance. Serdecznie zapraszamy do rejestracji!

Źródła:

M. Kucharzewski, E. Szkiler, G. Krasowski, M. Bartoszewicz, T. Banasiewicz, A. Chrapusta, Z Konrady, A Mirosz, B Aziewicz-Gabis, A Sieroń, G. Oszkinis, K. Strojek, Z. Rybak, „Algorytmy i wytyczne postępowania terapeutycznego w ranach trudno gojących się” w: Forum Leczenia Ran 2020;1(3), str. 95–116

A. Litwin, S. Rojek, W.Duszyńska, „Zakażenia o etiologii Pseudomonas aeruginosa u pacjentów oddziałów intensywnej terapii – charakterystyka mikrobiologiczna i możliwości terapeutyczne” w: Forum Zakażeń 2019;10(6), str. 395–403

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