INFEKTSIOONID GÜNEKOLOOGIAS Kadri Kermes TÜK Ühendlabor
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1 INFEKTSIOONID GÜNEKOLOOGIAS Kadri Kermes TÜK Ühendlabor
2 Normaalne tupe mikrofloora Laktobatsillid (produtseerivad piimhapet, peroksüdaasi, konkurents adhesioonil ja toitainete kasutamisel) pärsivad teiste mikroobide kasvu. Östrogeenid soodustavad glükogeeni deponeerumist tupe limaskesta rakkudes, see omakorda soodustab laktobatsillide kasvu Varieerub seoses hormonaalsete mõjudega nii elu kui menstruaaltsükli jooksul
3 Normaalne tupe mikrofloora Sündides vulva steriilne 24h koloniseerub naha saprofüütidega 2.,3.päev ema östrogeenid- laktobatsillide kasv 4.päev-prepuberteet põhiliselt soolefloorasse kuuluvad mikroobid Puberteet laktofloora tõus, domineerivad anaeroobid PMÜ/ml, aeroobe 100x vähem PMÜ/ml Postmenopaus laktofloora kadumine, naha ja soolefloora
4 Mikroobide esinemissagedus tervetel fertiilses eas naistel Ureaplasma urealyticum 78% Laktobatsillid 68% CoNS 66% Prevotella spp. 52% Gardnerella vaginalis 45% Peptostreptokokid 42% Streptokokid 38% Enterokokid 25% E.coli jt. enterobakterid 21% Mycoplasma hominis 20% Korüünebakterid 18% Candida spp. 11% Bacteroides fragilis grupp 11%
5 Urogenitaaltrakti infektsioonid 1.Tõeliste patogeenide põhjustatud infektsioonid 2. Normaalsesse mikrofloorasse kuuluvate mikroobide põhjustatud infektsioonid 3. Düsbiootilised seisundid, lõplikult tõestamata etioloogiaga seisundid
6 Tõeliste patogeenide põhjustatud infektsioonid Neisseria gonorrhoeae tservitsiit, PID, bartoliniit, uretriit Chlamydia trachomatis- tservitsiit, PID, bartoliniit, uretriit Trichomonas vaginalis - vulvovaginiit Mycoplasma genitalium tservitsiit, uretriit Mycobacterium tuberculosis- tservitsiit, vulvovaginiit HSV - tservitsiit, vulvovaginiit HPV - tservitisiit Treponema pallidum
7 Tõeliste patogeenide põhjustatud infektsioonide diagnostika Molekulaarsed meetodid Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma genitalium, Mycobacterium tuberculosis, HSV, HPV Seroloogilised meetodid Treponema pallidum, Chlamydia trachomatis, HSV Külv? (ajalugu) Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Mycobacterium tuberculosis, HSV, HPV
8 Normaalsesse mikrofloorasse kuuluvate mikroobide põhjustatud infektsioonid Candida spp. vulvovaginiit, balaniit, uretriit Enterokokid- endometriit, PID Streptokokid amnioniit, bartoliniit, tservitsiit, endometriit, PID, vulvovaginiit Enterobakterid- vulvovaginiit, amnioniit, bartoliniit, endometriit, PID Haemophilus influenzae- amnioniit, bartoliniit, endometriit, PID, uretriit U.urealyticum, U.parvum bartoliniit, uretriit, koorionamnioniit, PID Mycoplasma hominis PID, endometriit Anaeroobid bartoliniit, endometriit, PID
9 Düsbiootilised seisundid, lõplikult tõestamata etioloogiaga seisundid Bakteriaalne vaginoos (BV) Deskvamatiivne põletikuline vaginiit (DIV) Tsütolüütiline vaginoos Laktobatsilloos
10 Normaalsesse mikrofloorasse kuuluvate mikroobide põhjustatud infektsioonide ja düsbiootiliste seisundite diagnostika 1. Kliiniline pilt info laborile 2. Põletiku olemasolu - äigepreparaat 3. Oletatava tekitaja väljaselgitamine - aeroobne külv, seente külv, anaeroobne külv, ureaplasma külvid
11 Naiste genitaaltrakti materjalid TÜK Ühendlabori mikrobioloogia laboris 2007 muud materjalid; gün materjalid; 10590
12 Naiste urogenitaaltrakti materjalid 2007 tupp/külv 13% preparaat 12% emak/külv 75%
13 Äigepreparaat paralleelselt 2 alusklaasile (Gram ja Leishman Giemsa) Võimaldab hinnata põletikulist reaktsiooni ja oletatavaid tekitajaid Ideaalis tuleks teha kõigist urogenitaaltrakti materjalidest NB! Väga oluline emakaelakanali eelnev puhastamine limast
14 Sihtasutus Tartu Ülikooli Kliinikum Ühendlabor ÜHENDLABORI MIKROBIOLOOGIA LABOR Puusepa 1a, Tartu, tel ; SAATEKIRI BAKTERIOSKOOPILISEKS UURINGUKS Saatja asutus ja arst... Uuritav materjal... cervix Patsiendi nimi... tupp Diagnoos... ureetra Võtmise kuupäev Polümorfonukleaarsed leukotsüüdid... Domineerib gram... mikrofloora.. Clue rakud... Gram posit mf... Epiteelrakud Erütrotsüüdid... Gram negat mf... Märkused Seened... Analüüsi teostas... Trichomonas vaginalis... Vastuse kuupäev... ÜL-042 OÜ Tartumaa Trükikoda
15 Aeroobne külv Tupe eritis Emakaela eritis (PID kahtlusel, rasedatel, manipulatsioonide eelselt ESV, op)
16 Seenekülv Tupe eritis Mikroskoopia tundlikkus 65-85% Segakultuurina võib aeroobses külvis märkamata jääda
17 Anaeroobne külv Douglasi õõne punktaat Operatsioonil ja laparoskoopial saadud materjal Emakasisene vahend aktinomükoosi kahtluse korral
18 Ureaplasma külv Ureetra eritis Esimese joa uriin Emakakaela eritis Urogenitaaltrakti materjalide uuringutest moodustas 2005.aastal 3%, 2007.aastal 0,5% 2002 U. urealyticum biovarid 1 ja 2 nimetati ümber vastavalt U.parvum ja U.urealyticum U.parvum 50% tetm, kinoloon-resistentsus
19 U.urealyticum i tundlike tüvede osakaal PRI DOX TET JOS CLA AZI ERY OFL CIP
20 Informatsioon laborile Saatediagnoos (PID, kolpiit, korduvad tsüstiidid, rasedus, operatsiooni eelne kontroll, ESV soov) või kliinilised sümptomid (voolus, kõhuvalu, sügelus) KOH-testi tulemus Tupe ph (Menstruaaltsükli faas)
21 Tupe ph Menopaus 6-7,5 Menstruatsioon Sperma Antibakteriaalne, antifungaalne ravi Trihhomoniaas >6 DIV (AV) >5,5 BV >4,5 Normaalne 3,8-4,5 Laktobatsilloos 3,8-4,5 Kandidiaas 3,8-4,5 4 3 Tsütolüütiline vaginoos <4
22 Algdiagnoos uuringud tservitsiit PID vaginiit BV äigepreparaat aeroobne külv seente külv ureaplasma külv anaeroobne külv
23 tservitsiit Äigepreparaat (>20PMN) Tservitsiidi tekitajad tavakülvides välja ei kasva Emakakaela eritise aeroobne külv mõtestatud vaid PID, manipulatsioonide eelselt, rasedatel.
24 S.agalactiae kandluse skriining CDC 2002 rasedatel nädalal skriinida kõik rasedad (va raseduse jooksul uriinis S.agalactiae, eelmisel lapsel S.agalactiae infektsioon) Tupe alumisest ⅓ ja rektumist (selektiivne rikastus Todd-Hewitti puljong) Määrata tundlikkus klindamütsiini ja erütromütsiini suhtes
25 Bakteriaalne vaginoos (BV) Kalalõhnaline voolus Positiivne KOH-test Tupe ph > 4,5 Mikroskoopiline leid: võtmerakud, laktofloora puudumine, Gardnerella spp., Mobiluncus spp., Atopobium vaginae?
26 Schwiertz et al naist, kes pöördusid kolpiidile iseloomulike kaebustega günekoloogi vastuvõtule Kaebuste, günekoloogilise läbivaatuse, KOH testi ja wetmount mikroskoopia alusel esialgne diagnoos Värvitud preparaadi mikroskoopia, külv, PCR lõplik diagnoos Esialgne seenkolpiit valediagnoos 77% Esialgne BV valediagnoos 61% Schwiertz et al Ann Clin Microbiol Antimicrob. 2006; 5: 4.
27 Atopobium vaginae (1999) Anaeroobne grampositiivne kokobakter Produtseerib piimhapet Ei ole kultiveeritav, määramine PCR Leitud sageli koos Gardnerella spp. -ga Metronidasool-resistentne (ravi ebaõnnestumine), klindamütsiin tundlik Atopobium parvulum kaaries, hallitoos
28 BV diagnostika - äigepreparaat spetsiifilisus tundlikkus Homogeenne vesine voolus KOH-test 49% 87% 56% 34% Clue-rakud 92% 77%
29 Trihhomoniaas Natiivpreparaat Äigepreparaat PCR
30 Deskvamatiivne põletikuline vaginiit (DIV) või Aeroobne vaginiit (AV) Sümptomid meenutavad trihhomoniaasi Kollakas mädane halvalõhnaline voolus, põletustunne tupes, düspareuunia Äigepreparaadis rohkelt PMN leukotsüüte, parabasaalseid lameepiteelirakke, laktofloora puudub, esineb kokiline floora. Bakteriaalsetes külvides sageli S. agalactiae, E. coli, S.aureus. Mikroobide toksiinid + autoimmuunne reaktsioon (interleukiin -1ß ja interleukiin- 6 hulkade suurenemine) Ravi lokaalselt klindamütsiin (+ lokaalne hüdrokortikosteroid)
31 Kandidiaas Seenekülv Aeroobne külv Äigepreparaat Võimalus määrata antifungaalne tundlikkus
32 Candida spp. resistentsete tüvede osakaal flukonasool ketokonasool itrakonasool C.albicans Candida non-albicans
33 Tsütolüütiline vaginoos Sümptomid meenutavad kandidiaasi valkjas kohupiimamassi meenutav rohke tupeeritis, põletustunne, sügelus, düspareuunia. Kaebused ägenevad menstruaaltsükli luteaalfaasis. Happeline tupeeritis ph 3,5 Äigepreparaadis rakkude lüüsil vabanenud tsütoplasma fragmendid, lameepiteelrakkude tuumad, ülekaalus laktofloora (vale-võtmerakud). Seenekülv negatiivne. Raviks loputused söögisoodalahusega (2tl 1 liitri sooja vee kohta), istevannid (2-4 spl 5 cm sügavusele vanniveele 15 min 1-3 x nädalas Eelistada tampoonidele sidemeid
34 Laktobatsilloos Tsükliliselt korduvad menstruatsioonieelsed sümptomid meenutavad kandidiaasi. Tupe ph normaalne Preparaadis ülipikad laktobatsillid (anaeroobid, Leptothrix - Kaufmann 1994) Ravi Amoksütsilliinklavulaanhape 3x500mg 7p, alternatiiv doksütsükliin 2x100mg 10p
35 Uuringud vulvovaginiidi kahtlusel BV - äigepreparaat Trihhomoniaas äigepreparaat DIV (aerobic vaginitis) äigepreparaat + aeroobne külv Kandidiaas äigepreparaat + seenekülv Tsütolüütiline vaginoos äigepreparaat + seenekülv Laktobatsilloos äigepreparaat + seenekülv
36 Diagnoosid äigepreparaadi alusel 2007 Tservitsiit BV Naistekliinik n= % 1 go? % Nahakliinik n= % 79 30% Kandidiaas 61 6% 30 12% DIV 16 2% 6 2% Trihhomoniaas 1 0,1% 2 1%
37 Kokkuvõtteks Võimalikult palju kliinilist informatsiooni laborile Rohkem äigepreparaate Äigepreparaat + külv
38 Kirjandus P.Korenek, et al., Differentiation of the Vaginoses Bacterial Vaginosis, Lactobacillosis, and Cytolytic Vaginosis: The Internet Journal of Advanced Nursing Practice. 2003; Vol 6, Nr 1. G.G.G. Donders, et al., Aerobic vaginitis: Abnormal vaginal flora entity that is distinct from bacterial vaginosis, Best Practice & Research Clinical Obstetrics & Gynaecology, Volume 21, Issue 3, June 2007, Pages E. Newbern, B. Foxman, D. Leaman and J.D. Sobel, Desquamative Inflammatory Vaginitis: An Exploratory Case-Control Study Annals of Epidemiology, Volume 12, Issue 5, July 2002, Pages
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