antibioticsАнтибиотики и ХимиотерапияAntibiot Khimioter = Antibiotics and Chemotherapy0235-2990ООО «Издательство ОКИ»10.37489/0235-2990-2020-65-5-6-41-69antibiotics-739Research ArticleОБЗОРЫREVIEWSИнфекции, вызванные карбапенеморезистентными энтеробактериями: эпидемиология, клиническое значение и возможности оптимизации антибактериальной терапииInfections Caused by Carbapenem-Resistant Enterobacterales: Epidemiology, Clinical Significance, and Possibilities for Antibiotic Therapy Optimizationhttps://orcid.org/0000-0001-7606-8608ЯковлевС. В.YakovlevS. V.

Яковлев Сергей Владимирович — д. м. н., профессор кафедры госпитальной терапии №2 Института клинической медицины

115446, Москва, Коломенский проезд 4, ГКБ им. С. С. Юдина, кафедра госпитальной терапии №2

Moscow

https://orcid.org/0000-0002-1389-6454СувороваМ. П.SuvorovaM. P.

Суворова Маргарита Петровна — к. м. н., доцент кафедры госпитальной терапии №2 Института клинической медицины

Москва

Moscow

https://orcid.org/0000-0001-5244-7769БыковА. О.BykovA. O.

Быков Андрей Олегович — аcсистент кафедры анестезиологии и реаниматологии, врач-реаниматолог ГКБ №40 ДЗ Москвы

Москва

Moscow

Первый Московский государственный медицинский университет им. И. М. Сеченова (Сеченовский Университет)РоссияI. M. Sechenov First Moscow State Medical University (Sechenov University)Russian FederationРоссийский национальный исследовательский университет им. Н. И. ПироговаРоссияPirogov Russian National Research Medical UniversityRussian Federation202026082020655-64169Copyright © ООО «Издательство ОКИ», 20202020ООО «Издательство ОКИ»ООО «Издательство ОКИ»https://www.antibiotics-chemotherapy.ru/jour/about/submissions#copyrightNoticehttps://www.antibiotics-chemotherapy.ru/jour/article/view/739

Устойчивость бактерий порядка Enterobacterales к карбапенемам может быть реализована разными механизмами, но наиболее распространённый — ферментативный, связанный с продукцией карбапенемаз. Карбапенемазы энтеробактерий характеризуются большим разнообразием; они представлены в трёх классах бета-лактамаз. Наиболее известные карбапенемазы относятся к классам А (ферменты KPC, GES), D (OXA-48) и B (металлоэнзимы NDM, VIM, IMP). Приводятся подробные их клинико-микробиологические характеристики, а также рекомендации по детекции. Карбапенемазы распространены повсеместно, в работе обсуждаются географические особенности распространения карбапенемаз в разных регионах мира; в России наибольшее распространение получили ферменты OXA-48 и NDM. Обсуждается клиническое значение карбапенемаз и факторы риска этих инфекций, к которым относятся: 1) предшествующая терапия карбапенемами; 2) высокий уровень карбапенемаз в отделении; 3) колонизация кишечника карбапенемазопродуцирующими энтеробактериями; 4) поездка в регион с высокой распространённостью карбапенемаз (4-й и 5-й эпидемиологический уровень). Обсуждаются возможности антибактериальной терапии инфекций, вызванных карбапенеморезистентными энтеробактериями, детально разбираются клинико-фармакологические характеристики антибиотиков (цефтазидим/авибактам, азтреонам, карбапенемы, полимиксины, тигециклин, фосфомицин), их эффективность и схемы терапии. Приводятся актуальные клинические данные, показывающие эффективность цефтазидима/авибактама в монотерапии при инфекциях, вызванных продуцентами карбапенемаз OXA-48 и KPC. Обсуждаются тактические вопросы ведения таких пациентов. Представлены алгоритмы эмпирической и целенаправленной терапии инфекций, вызванных карбапенемоустойчивыми энтеробактериями.

The resistance of Enterobacterales to carbapenems can be realized by different mechanisms, but the most common one is enzymatic, associated with the production of carbapenemases. Carbapenemases of enterobacteria are characterized by a wide variety; they are represented in three classes of beta-lactamases. The most well-known carbapenemases belong to classes A (KPC, GES enzymes), D (OXA-48), and B (metalloenzymes — NDM, VIM, IMP). Detailed clinical and microbiological characteristics of carbapenemases are given, as well as recommendations for their detection. Carbapenemases are widespread, and the paper discusses the geographical distribution of carbapenemases in different regions of the world; OXA-48 and NDM are the most widely distributed enzymes in Russia. The clinical significance of carbapenemases and risk factors for these infections are discussed, including the following: 1) previous carbapenem therapy; 2) high levels of carbapenemases in the Department; 3) colonization of the intestine with carbapenemase-producing enterobacteria; 4) traveling to regions with a high prevalence of carbapenemases (4th and 5th epidemiological levels). The possibilities of antibacterial therapy of infections caused by carbapenem-resistant enterobacteria are discussed, the clinical and pharmacological characteristics of different antibiotics (ceftazidime/avibactam, aztreonam, carbapenems, polymyxins, tigecycline, fosfomycin), their effectiveness and treatment options are analyzed in detail. Current clinical data showing the effectiveness of ceftazidime/avibactam monotherapy for infections caused by carbapenemase producers OXA-48 and KPC are presented. Practical issues of management of such patients are discussed. Algorithms for empirical and targeted therapy of infections caused by carbapenem-resistant enterobacteria are presented.

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The authors declare that there are no conflicts of interest present.