MEDICINSKI GLASNIK

MEDICINSKI GLASNIK 

Official publication of the Medical Association of Zenica-Doboj Canton, Bosnia and Herzegovina 

Volume 6 Number 2, August 2009. 

ISSN 1840-0132

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Medicinski Glasnik 

Official Publication of the Medical Association of 

Zenica-Doboj Canton 

Bosnia and Herzegovina 

Editorial Board 

Editor-in-chiEf 

Selma Uzunović-Kamberović 

Zenica, Bosnia and Herzegovina 

tEchnical Editor 

Harun Drljević 


Editors 

Adem Balić, Tuzla, Bosnia and Herzegovina 

Dubravka Bartolek, Zagreb, Croatia 

Branka Bedenić, Zagreb, Croatia 

Asja Čelebić, Zagreb, Croatia 

Josip Čulig, Zagreb, Croatia 

Filip Čulo, Mostar, Bosnia and Herzegovina 

Jordan Dimanovski, Zagreb, Croatia 

Branko Dmitrović, Osijek, Croatia 

Davorin Đanić, Slavonski Brod, Croatia 

Lejla Ibrahimagić-Šeper, Zenica, Bosnia and Herzegovina 

Tatjana Ille, Belgrade, Serbia 

Vjekoslav Jerolimov, Zagreb, Croatia 

Mirko Šamija, Zagreb, Croatia 

Ines Drenjančević-Perić, Osijek, Croatia 

Sven Kurbel, Osijek, Croatia 

Snježana Pejičić, Banja Luka, Bosnia and Herzegovina 

Belma Pojskić, Zenica, Bosnia and Herzegovina 

Asja Prohić, Sarajevo, Bosnia and Herzegovina 

Velimir Profozić, Zagreb, Croatia 

Zlatko Puvačić, Sarajevo, Bosnia and Herzegovina 

Radivoje Radić, Osijek, Croatia 

Amira Redžić, Sarajevo, Bosnia and Herzegovina 

Suad Sivić, Zenica, Bosnia and Herzegovina 

Sonja Smole-Možina, Ljubljana, Slovenia 

Vladimir Šimunović, Mostar, Bosnia and Herzegovina 

Adrijana Vince, Zagreb, Croatia 

Jasmina Vraneš, Zagreb, Croatia 

Živojin Žagar, Zagreb, Croatia 

Secretary: Tatjana Žilo; 

Proofreaders: Aras Borić (Bosnian, Croatian, Serbian), 

Glorija Alić (English), 

Cover: Jasmin Kukavica

MEDICINSKI GLASNIK 

Official Publication of the Medical Association of Zenica-Doboj Canton, Bosnia and Herzegovina 

Volume 6, Number 2, August 2009 

Free full-text online at: www.ljkzedo.com.ba, and www.doaj.org (DOAJ, Directory of Open Access 

Journals) 

Review 147 Značenje nastanka mikrobnog biofilma u patogenezi i liječenju kroničnih 

infekcija 

Significance of microbial biofilm occurence in the pathogenesis and treatment 

of chronic infections 

Jasmina Vraneš, Vladimira Leskovar 

Original 

article 

166 Effect of inoculum size of Enterobacteriaceae producing SHV and 

CTX-M extended-spectrum β-lactamases on the susceptibility to β-lactam 

combinations with inhibitors and carbapenems 

Branka Bedenić, Jasmina Vraneš, Nataša Beader, Ines Jajić-Benčić, Vanda 

Plečko, Selma Uzunović-Kamberović, Smilja Kalenić 

173 Comparison of the frequency and the occurrence of antimicrobial 

resistance among C. jejuni and C. coli isolated from human infections, 

retail poultry meat and poultry in Zenica-Doboj Canton, Bosnia and 

Herzegovina 

Selma Uzunović-Kamberović, Tina Zorman, Ingrid Berce, Lieve Herman, 

Sonja Smole Možina 

181 Atelektaza pluća i infekcije donjih dišnih puteva u djece na odjelu za 

intenzivno liječenje 

Lung atelectasis and lower respiratory tract infections in children in the 

intensive care unit 

Nada Mladina, Devleta Hadžić, Amela Selimović 

188 Evaluacija dijagnostičke vrijednosti Interleukina-6 i C-reaktivnog 

proteina iz krvi pupčanika u prepoznavanju rane infekcije terminske 

novorođenčadi male porođajne mase 

Diagnostic value of Interleukin 6 and C-reactive protein from umbilical cord 

blood in recognition of early infection in term newborns with low birth weight 

Almira Ćosićkić, Fahrija Skokić, Selmira Brkić 

197 Alterations in body weight and biochemistry in patient treated with different 

psychotropic drugs in a clinic in Istanbul 

Aliye Ozenoglu, Serdal Ugurlu, Huriye Balci, Gunay Can, Funda Elmacıoglu, 

Yeltekin Demirel, Engin Eker 

203 Klinička revizija lipidnog statusa kod tipa 2 dijabetesa na nivou timova 

obiteljske medicine u općini Zenica, Bosna i Hercegovina 

Audit of lipids control level for Diabetes Mellitus type 2 patients done by 

Family Medicine Teams in Zenica, Bosnia and Hercegovina 

Larisa Gavran, Selmira Brkić 

211 Učestalost pušenja i nikotinska ovisnost kod medicinskih radnika 

Incidence of smoking and nicotine depedence among medical workers 

Željko Martinović, Cvita Martinović, Mladen Čuturić 

218 Smoking is the most frequent risk factor for cardiovascular diseases in 

Croatian Western region: findings of the Croatian health survey 2003. 

Đulija Malatestinić, Nena Rončević, 1 Henrietta Benčević-Striehl, Suzana 

Janković, Vladimir Mićović

Case 

report 

Erratum 284 

227 Influence of different glass fiber reinforcements on denture base polymer 

strength (Fiber reinforcements of dental polymer) 

Denis Vojvodić, Dragutin Komar, Zdravko Schauperl, Asja Čelebić, Ketij 

Mehulić, Domagoj Žabarović 

235 Influence of cast surface finishing process on metal-ceramic bond strength 

Ketij Mehulić, Martina Lauš-Šošić , Zdravko Schauperl, Denis Vojvodić, Sanja 

Štefančić 

243 Use of digital photography in the reconstruction of the occlusal plane 

orientation 

Nikola Petričević, Marko Guberina, Robert Ćelić, Ketij Mehulić, Marko 

Krajnović, Robert Antonić, Josipa Borčić, Asja Čelebić 

249 A three-dimensional evaluation of microleakage of the class V cavities 

restored with flowables 

Paris Simeon, Silvana Jukić-Krmek, Goranka Prpić-Mehičić, Ivica Smojver, 

Ivica Anić, Ivica Pelivan 

256 Oral health of the Croatian army recruits in 2001 

Tomislav Badel, Jadranka Keros, Vjekoslav Jerolimov, Nikša Dulčić, Snježana 

Restek Despotušić 

261 Security perception of a portable PC user (The difference between medical 

doctors and engineers): a pilot study 

Krešimir Šolić, Vesna Ilakovac 

265 Akutna bruceloza udružena sa Coombs-pozitivnom autoimunosnom 

hemolitičkom anemijom i diseminiranom intravaskularnom koagulacijom 

Acute brucellosis associated with Coombs-positive autoimmune hemolytic 

anemia and disseminated intravascular coagulation (DIC) 

Nerma Mušić 

268 Pneumolabirint 

Pneumolabyrinth 

Đenad Hodžić 

271 Sphenochoanal polyposis 

Ivana Pajić-Penavić, Davorin Đanić, Ljubica Fuštar-Preradović 

274 Primary extranodal Natural Killer/T-cell lymphoma of the ethmoid sinus 

masquerading as orbital cellulites 

Davorin Đanić, Ana Đanić Hadžibegović, Ivana Mahovne 

277 Knee disarticulation 

Ognjen Živković, Antun Muljačić, Renata Poljak-Guberina 

280 Izvanmaternična trudnoća izliječena metrotreksatom 

Extrauterine pregnancy treated with Metrotrexat 

Ljiljana Bilobrk Josipović, Branka Lovrinović, Anton Galić 

Medicinski Glasnik is indexed by EMBASE (Exerpta Medica), Scopus, Science Citation Index Expanded 

(SciSearch ® ), Journal Citation Reports/Science Edition and EBSCO

REVIEW 

Značenje nastanka mikrobnog biofilma u patogenezi i liječenju 

kroničnih infekcija 

Jasmina Vraneš 1, 2 , Vladimira Leskovar 2 

1 2 Katedra za medicinsku mikrobiologiju, Medicinski fakultet Sveučilišta u Zagrebu, Služba za mikrobiologiju, Zavod za javno zdravstvo 

“Dr. Andrija Štampar“; Zagreb, Hrvatska 

Corresponding author: 

Jasmina Vraneš, 

Zavod za javno zdravstvo “Dr. Andrija 

Štampar“, 

Mirogojska cesta 16, 10 000 Zagreb, 

Hrvatska 

Phone: +385 1 4696 197; 

Fax: +385 1 4678 006; 

E-mail: jasmina.vranes@stampar.hr 

Originalna prijava: 

06. april 2009.; 

Korigirana verzija: 

08. april 2009.; 

Prihvaćeno: 

03. maj 2009. 

Med Glas 2009; 6(2):147-165 

SAŽETAK 

Sposobnost adherencije bakterija na biotičke i abiotičke površine, 

funkcioniranje kao zajednica, te međusobna komunikacija bakterijskih 

stanica, od posebne su važnosti u nastanku kroničnih infektivnih 

bolesti. Sesilna zajednica mikroorganizama, danas poznata 

kao biofilm, povezuje se s brojnim bakterijskim infekcijama. 

Ključne karakteristike biofilm-infekcija jesu perzistencija infekcije, 

te rezistencija na antimikrobne lijekove i obranu imunološkog 

sustava domaćina. Napretkom tehnologije i primjenom novih mikroskopskih 

i molekularnih metoda u proučavanju ultrastrukture i 

funkcionalnim odnosima unutar biofilma, nastoji se pronaći novi 

terapijski pristup u kontroli biofilm-infekcija, koje su jedan od 

najvećih izazova 21. stoljeća. 

Ključne riječi: biofilm, kronične infekcije, patogeneza, liječenje 

147

148 

Medicinski Glasnik, Volumen 6, Number 2, August 2009 

UVOD 

U prirodi mikroorganizmi mogu egzistirati 

kao planktonski organizmi - individualne stanice 

koje slobodno plivaju u tekućem mediju; ili 

u obliku sesilne zajednice - biofilma. Biofilm je 

izrazito rasprostranjen način života u okolišu, 

gotovo na svakoj granici vode i zraka, te zemlje 

i vode (1, 2). U protekla dva desetljeća definicija 

biofilma se neprestano mijenjala jer svako 

novo istraživanje nadograđuje postojeće znanje 

o stvaranju, strukturi, sazrijevanju, te rezistenciji 

biofilma. Objedinjenjem spoznaja o već 

poznatim karakteristikama, te novootkrivenim 

fiziološkim osobinama, biofilm je danas definiran 

kao sesilna zajednica mikroorganizama čije 

su stanice ireverzibilno povezane sa supstratom i 

međusobno, te uklopljene u izvanstanični matriks 

polisaharidnih polimera koji su same stvorile, a 

ispoljavaju izmijenjen fenotip uslijed promijenjene 

brzine razmnožavanja i transkripcije gena 

koje ne uočavamo u planktonskih organizama (3). 

Formiranje biofilma započinje kondicioniranjem 

neke površine polimerima iz vodenog okoliša što 

omogućuje adherenciju mikroorganizama (2). 

Površine na kojima se može naći biofilm jesu, 

primjerice, metal, plastika, kamen, čestice zemlje, 

medicinski implantati, te tkiva (2). Nakon 

početnog, reverzibilnog vezivanja planktonskih 

stanica za površinu supstrata, slijedi stvaranje stabilne 

veze posredovane adhezinima na staničnoj 

stijenki bakterija, a potom proliferacija, te nakupljanje 

bakterijskih stanica u višeslojne stanične 

nakupine i stvaranje izvanstaničnog polisaharidnog 

matriksa. Održavanje takve višestanične zajednice 

bilo bi teško bez postojanja međustanične 

komunikacije bakterijskih stanica, posredovane 

malim signalnim molekulama sa sposobnošću 

difuzije u izvanstanični okoliš (4). Nakupljanje 

signalnih molekula u okolišu omogućuje svakoj 

pojedinoj bakterijskoj stanici procjenu stanične 

gustoće, odnosno ukupnog broja bakterija, a ta se 

pojava naziva detekcija kvoruma (engl. quorum 

sensing). Signalne molekule u gram-negativnih 

bakterija jesu N-acil-homoserinski laktoni (AHL), 

a u gram-pozitivnih su mali ili modificirani peptidi 

(Slika 1) (4). Koncentracija signalnih mole- 

kula postignuta pri točno određenoj, kritičnoj 

gustoći stanica, postaje dovoljna za aktivaciju 

gena uključenih u sintezu faktora virulencije ili 

sekundarnih metabolita (4, 5). Maturacija biofilma 

odvija se u pet razvojnih stadija (6). Prvi stadij 

je reverzibilno povezivanje, u kojem se planktonske 

stance tek kratkotrajno povezuju sa supstratom, 

a nakon toga slijedi drugi stadij, ireverzibilno 

povezivanje, u kojem se planktonske stanice 

čvrsto vežu na površinu supstrata i gube svojstvo 

pokretljivosti (6). Treći stadij jeste maturacija I za 

koji je karakteristično stvaranje izvanstaničnog 

matriksa, te povećavanje i višeslojnost mikrokolonijâ 

(6). Mikrokolonije, najčešće gljivolikog ili 

stupićastog izgleda, svoju maksimalnu veličinu 

dosežu u stadiju maturacije II (6). Proces maturacije 

biofilma završava petim stadijem, disperzijom, 

u kojem se između mikrokolonija formiraju 

vodeni kanalići, a same mikrokolonije mijenjaju 

svoj oblik u školjkasti, uslijed izdvajanja bakterijskih 

stanica smještenih u središnjem dijelu 

mikrokolonija u potrazi za novim i boljim izvorom 

hranjivih tvari (6). Biofilm može činiti samo 

jedna bakterijska vrsta, no češće se sastoji od više 

vrsta bakterija, ili bakterija i gljiva (1, 3). Jednom 

pričvršćeni za površinu, mikroorganizmi biofilma 

mogu, svojim aktivnostima, doprinositi ili štetiti 

zbivanjima u okolišu, ovisno o uvjetima koji u 

njemu vladaju. Poznato je da ove sesilne zajednice 

sudjeluju u razgradnji brojnih onečišćivača 

okoliša, stvaranju i razgradnji organske tvari, te 

u kruženju dušika, sumpora i drugih elemenata u 

prirodi (7-10). Prije saznanja o postojanju, strukturi 

i karakteristikama biofilma, biotehnolozi su 

već koristili prednosti biofilma u sustavima za 

pročišćavanje voda, pri uklanjanju opasnih tvari 

koje su kontaminirale zemlju i podzemne vode, 

te pri ekstrakciji plemenitih metala iz rudače (11- 

13). No, pozitivna djelovanja biofilma daleko su 

Slika 1. Stvaranje biofilma (Alma Šimunec Jović, 2007.)

jeđa od štetnih koja uzrokuju ogromne ekonomske 

gubitke u agrokulturi i industriji, te mnogobrojne 

probleme u medicini. Biofilm se povezuje 

sa stafilokoknim mastitisom u goveda (14), biokorozijom 

(deterioracijom metalnih materijala 

u prisutnosti biofilma) vodenih sustava u industriji 

(15), te naftnih cjevovoda (16), kao i problemima 

u industriji prehrambenih i papirnatih 

artikala (17-18). U medicini biofilm se povezuje 

s brojnim kroničnim infekcijama (1), te različitim 

infekcijama biomaterijala poput kateterâ, protezâ, 

implantatâ, te drugih medicinskih naprava 

od metala ili plastičnih polimera koji se nalaze u 

ljudskom organizmu (1, 19). Prema procjenama 

Centra za kontrolu bolesti i prevenciju iz Atlante, 

biofilm se povezuje s gotovo dvije trećine bakterijskih 

infekcija (3). Brojnost, kroničan tijek, te 

rezistencija na antimikrobnu terapiju, tek su neke 

od značajki biofilm-infekcija, koje su jedan od 

najvećih izazova medicine 21. stoljeća. 

REZISTENCIJA BIOFILMA 

Perzistencija infekcija uzrokovanih mikrobnim 

biofilmom kontinuirano motivira istraživače 

u potrazi za jedinstvenim mehanizmom rezistencije 

biofilma, kako na antimikrobne lijekove, 

tako i na dezinfekcijska sredstva (3). Poznato 

je da su bakterije, unutar biofilma, 10-1.000 

puta rezistentnije na djelovanje antimikrobnih 

lijekova nego planktonske stanice, što govori u 

prilog postojanja mehanizma rezistencije kojeg 

potencijalno posjeduju svi patogeni, no koji 

se ispoljava samo pri tvorbi biofilma (20, 21). 

Proučavanjem biofilma takav mehanizam još nije 

utvrđen, niti su otkriveni mutanti u planktonskim 

kulturama koji bi govorili tomu u prilog (21), 

pa se trenutno rezistencija biofilma objašnjava 

tek hipotezama. Hipoteze starijeg datuma, kao 

moguće mehanizme rezistencije, navode oslabljenu 

difuziju antimikrobnih lijekova u biofilm 

(20, 22) ili promjene u mikrookolišu biofilma 

koje utječu na brzinu razmnožavanja mikroorganizama, 

odnosno djelotvornost antimikrobnih 

lijekova u dubini biofilma (20, 22). Oslabljena 

difuzija antimikrobnih lijekova objašnjava se 

dvojako; s jedne strane, interakcijom molekula 

Vraneš et al Biofilm i kronične infekcije 

s egzopolisaharidnim matriksom biofilma, koji 

djeluje poput ‘’molekularnog sita’’ na velike 

molekule ili kao ionski izmjenjivač na hidrofilne, 

pozitivno nabijene molekule antimikrobnih 

lijekova (1, 22, 23); te, s druge strane, enzimskom 

razgradnjom, kojom se biofilm štiti od 

molekula, kao, primjerice, vodikovog peroksida 

ili β-laktamskih antimikrobnih lijekova (20, 23). 

Kao što je vidljivo, primjenjivost ove hipoteze 

ovisna je o prirodi samog lijeka, no nisu svi antimikrobni 

lijekovi visokoreaktivne molekule 

poput, primjerice, aminoglikozida, pa ih većina, 

vjerojatno, ipak penetrira u biofilm (23). Biofilm 

je prostorno heterogeničan (24). S porastom debljine 

slojeva stanica u biofilmu, mijenjaju se 

i uvjeti mikrookoliša, poput dostupnosti hranjivih 

tvari, prisutnosti kisika ili kiselih otpadnih 

metaboličkih tvari (20, 22, 25). Sve to utječe 

na brzinu razmnožavanja bakterijskih stanica, 

koje, u takvim uvjetima, prelaze u stacionarnu 

fazu u kojoj su manje osjetljive na baktericidno 

djelovanje antimikrobnih lijekova, osobito onih 

čije je ciljno mjesto djelovanja sinteza makromolekula 

(26). Novija hipoteza jeste hipoteza 

perzistera. Većina stanica biofilma, kao i planktonske 

stanice koje se oslobađaju s površine biofilma, 

osjetljive su na antimikrobnu terapiju (23, 

27). Naprotiv, samo mala frakcija stanica (0,1- 

10% svih stanica biofilma) neosjetljiva je na 

produženu izloženost ili više koncentracije antimikrobnih 

lijekova, te perzistira usprkos terapiji 

(26). Premda su perzisteri otkriveni još sredinom 

20. stoljeća u planktonskim kulturama (21), 

o njihovoj se prirodi još uvijek malo zna. Za sada 

je poznato da perzisteri nisu mutanti (21), te da 

ne predstavljaju poseban stadij staničnog ciklusa 

bakterija (23). Pretpostavlja se da je riječ o fenotipskoj 

varijanti koja je, iz divljeg tipa, spontano 

ušla u stanje promjenjivih fenotipskih obilježja 

(26). Mehanizam nastanka perzistera još je manje 

poznat. Do sada je utvrđeno da ove stanice ne 

nastaju kao odgovor na antimikrobnu terapiju 

(21, 27), te da bakterijske signalne molekule, 

kojima se detektira stanična gustoća, nemaju 

nikakva utjecaja na stvaranje perzistera (21, 27). 

U novije vrijeme pretpostavlja se da u kontroli 

stvaranja perzistera sudjeluju dva procesa. Jedan 

149

150 


je promjena razine specifičnih perzister-proteina 

(27), ovisno o fazi razvitka biofilma (21), a 

drugi je kontroliranje razine ekspresije tih proteina, 

koja ovisi o gustoći stanica (27), te o faktorima 

mikrookoliša, poput niske koncentracije 

supstrata (26). Misli se da perzister-proteini induciraju 

prelazak bakterija u stanje mirovanja, 

tzv. dormant fazu (27), što rezultira tolerancijom 

na antimikrobne lijekove uslijed utišane 

ekspresije gena u biosintetskim putevima ovih 

stanica, a time i onemogućavanjem djelovanja 

lijekova na njihova ciljna mjesta (21, 27). Ako 

znamo da perzisteri postoje i u planktonskim 

kulturama (23, 27), onda se nameće pitanje 

kako perzisteri biofilma doprinose njegovoj visokoj 

rezistenciji. Odgovor leži u sinergističkom 

djelovanju imunološkog sustava i antimikrobnih 

lijekova. Dok imunološki sustav uništava i 

uklanja zaostale planktonske perzistere (21, 23, 

27), spram perzistera biofilma je nemoćan jer 

su ovi zaštićeni egzopolisaharidnim matriksom 

(23, 27) i nakon što se smanji koncentracija lijeka 

(21, 27) ili prekine terapija uslijed nestanka 

simptoma bolesti (23), perzisteri obnavljaju biofilm, 

oslobađaju se nove planktonske stanice i 

simptomi bolesti se vraćaju (21, 23). 

ULOGA BIOFILMA U NASTANKU KRONIČNIH 

INFEKCIJA U LJUDI 

Akutne bakterijske infekcije, koje izazivaju 

planktonski oblici patogenih bakterija, stoljećima 

su odnosile ljudske živote. Razvoj antimikrobnih 

lijekova i cjepiva omogućio je stjecanje kontrole 

nad ovim akutnim bolestima, te se može reći da 

one sada, uglavnom, pripadaju prošlosti. Sredinom 

prošlog stoljeća započela je postantibiotska 

era, odnosno era biofilm-infekcija. Ove infekcije 

perzistiraju mjesecima i godinama, izmjenjuju se 

periodi odsutnosti kliničkih simptoma infekcije s 

akutnim egzacerbacijama, manje su agresivne od 

akutnih infekcija, te pogađaju umjereno kompromitirane 

osobe (28). Uzročnici biofilm-infekcija 

jesu bakterijske vrste koje se nalaze u okolišu ili 

koje nalazimo kao komenzale ljudskog organizma 

(3, 29), a koje već stoljećima, u svom prirodnom 

okolišu, postoje u obliku biofilm-zajednice. 

Biofilm se, u ljudskom organizmu, razvija na 

vitalnom ili nekrotičnom tkivu, te na inertnim 

površinama različitih biomaterijala (29). Bez 

obzira radi li se o kroničnoj infekciji ili o infekciji 

biomaterijala, ove biofilm-infekcije imaju 

iste kliničke karakteristike, a to su spor nastanak 

na jednom ili više mjesta u organizmu, te kasna 

pojava simptoma bolesti (29). Nekoliko karakteristika 

biofilm čini jedinstvenim u procesu 

nastanka infekcije. Prva od njih jeste mogućnost 

disperzije stanica ili agregata biofilma, što može 

rezultirati nastankom embolusa, ili pak infekcijom 

mokraćnog ili krvožilnog sustava (2, 30). 

Disperzija pojedinih stanica nastaje uslijed odvajanja 

stanica-kćeri iz aktivno-razmnožavajućih 

stanica, te kao posljedica promjene dostupnosti 

hranjivih tvari ili detekcije kvoruma (2), a 

odvajanje manjih dijelova biofilma nastaje pod 

utjecajem brzine protoka tekućine u neposrednoj 

blizini površine biofilma (2, 30). Dok pojedine 

stanice, ubrzo nakon odvajanja, poprimaju 

fenotip planktonskih stanica, čini se da čestice 

biofilma zadržavaju određene karakteristike biofilma, 

poput antimikrobne rezistencije (2, 30). 

Antimikrobnom terapijom eradiciraju se planktonske 

stanice oslobođene iz biofilma, što rezultira 

povlačenjem simptoma akutne egzacerbacije 

bolesti, no ne uspjeva se uništiti sesilna zajednica 

(2, 29, 30). Rekurirajući simptomi biofilm-infekcije 

u konačnici će nestati tek nakon uklanjanja 

biofilma kirurškim zahvatom ili odstranjenjem 

inficiranog biomaterijala (29, 30). Slijedeća jedinstvena 

karakteristika biofilm- infekcija jeste rezistencija 

biofilma na stanični i humoralni odgovor 

imunološkog sustava domaćina. U početku se 

smatralo da rezistenciji pridonosi interferencija 

egzopolisaharidnog matriksa biofilma s kemotaksijom 

polimorfonuklearnih leukocita (PMN) 

(31), te s prodorom baktericidnih i opsonizirajućih 

protutijela (28, 31). Danas je poznato da aktivirani 

PMN penetriraju u biofilm, ulaze u vodene 

kanaliće, te penetriraju u mikrokolonije, no 

tamo ne uspijevaju fagocitirati stanice biofilma 

koje se nalaze u njihovoj neposrednoj blizini 

(32). Mehanizam ove neuspješne fagocitoze tek 

predstoji objasniti (32). Opsonizirajuća protutijela, 

dio humoralne obrane, u slučaju biofilm-

infekcije, dijele sudbinu polimorfonuklearnih 

leukocita. Iako prodiru u dubinu biofilma (33), 

u matriks ulaze u interakciju s antigenima koji 

su tamo u suvišku, te uslijed toga ne dospijevaju 

do antigena na površini stanica biofilma, što 

onemogućuje njihovo opsonizirajuće djelovanje 

i posljedično uništavanje stanica biofilma (33). 

Perzistencija kroničnih infekcija, nemogućnost 

detekcije mikrobnog uzročnika standardnim 

mikrobiološkim tehnikama kultivacije u većini 

slučajeva, te neuspjeh antimikrobne terapije 

i imunološkog sustava domaćina u eradikaciji 

uzročnika, naveli su neke znanstvenike na 

pomisao da kronične infekcije uzrokuje biofilm. 

Ovu tezu valjalo je potkrijepiti istraživanjem 

sesilnih zajednica in situ, što, uslijed nedostatka 

raspoloživih metoda, nije bilo ostvarivo sve do 

unazad dvadesetak godina. Razvoj i primjena 

konfokalnog skenirajućeg laserskog mikroskopa 

(engl. confocal scanning laser microscope, 

CSLM) omogućila je istraživanje ultrastrukture 

biofilma (1-3), a nove molekularne tehnologije, 

poput primjene fluorescentnih rRNK-usmjerenih 

proba, te fluorescentne in situ hibridiza- 

Kronična infekcija 

Chronic infection 

Endokarditis nativnih valvula 

Native valve endocarditis 

Periodontitis 

Periodontitis 

Cistična fibroza 

Cystic fibrosis 

Kronični bakterijski prostatitis 

Chronic bacterial prostatitis 

Kronični cistitis 

Chronic cystitis 

Inficirani bubrežni kamenci 

Infected kidney stones 

Kronični otitis media 

Chronic otitis media 

Mišićno-koštane infekcije 

Musculoskeletal infections 

Nekrotizirajući fasciitis 

Necrotizing fasciitis 

Infekcije bilijarnog sustava 

Biliary tract infection 

Osteomijelitis 

Osteomyelitis 

Meloidoza 

Meloidosis 

Kronične rane 

Chronic wounds 

cije (FISH), doprinijele su identifikaciji i kvantifikaciji 

uzročnikâ biofilma, te razumijevanju 

njihovih međusobnih funkcionalnih odnosa (1). 

Mogućnost vizualizacije i proučavanja biofilma 

na biomaterijalima, te u humanim uzorcima, rezultirala 

je intenzivnim istraživanjima brojnih 

infekcija i njihove povezanosti sa stvaranjem 

biofilma (13). Danas se biofilm, uz infekcije biomaterijala, 

povezuje s brojnim kroničnim infekcijama. 

Najčešće kronične infekcije, te njihove 

uzročnike, prikazuje Tablica 1. 

PERIODONTITIS 

U periodontalne bolesti ubraja se cijeli 

niz poremećaja potpornog tkiva zubi, od kojih 

pobolijeva gotovo 90% svjetske populacije. 

Najblaži oblik periodontalne bolesti je gingivitis, 

reverzibilna upala gingive (desni), a najteži, 

kronični periodontitis, kronična destrukcija periodontalnog 

tkiva (gingive, periodontalnog ligamenta 

i alveolarne kosti) koji može rezultirati 

gubitkom zubi (3). Primarno mjesto periodontalne 

infekcije jeste prostor između korijena zuba 

Uobičajen bakterijski patogen biofilma 

Common biofilm bacterial pathogen 

Streptokoki viridans grupe 

Viridans group streptococci 

Gram-negativne anaerobne bakterije 

Gram-negative anaerobic bacteria 

Pseudomonas aeruginosa 

Pseudomonas aeruginosa 

Gram-negativne enterobakterije 

Gram-negative enterobacteria 

Uropatogena Escherichia coli 

Uropathogenic Escherichia coli 

Ureaza-producirajuće enterobakterije 

Ureasa-producing enterobacteria 

Haemophylus influenzae, Streptococcus pneumoniae 

Haemophylus influenzae, Streptococcus pneumoniae 

Gram-pozitivni aerobni koki 

Gram-positive aerobic cocci 

Streptococcus pyogenes 

Enterobacteriaceae 


Tablica 1. Najčešći uzročnici kroničnih infekcija povezanih s biofilmom (The most common etiology of chronic infections involving 

biofilm) 

Različite bakterijske i gljivične vrste 

Various bacterial and fungal species 

Pseudomonas pseudomallei 

Pseudomonas pseudomallei 

Različite aerobne i anaerobne bakterijske vrste 

Various aerobic and anaerobic bacterial species 

151

152 


i gingive, koji se naziva subgingivalna pukotina, 

a koji se, s progresijom bolesti, može produbiti u 

periodontalni ‘’džep’’. Inače, smatra se da periodontitis 

nastaje kao posljedica poremećaja ekvilibrija 

u dentalnom plaku (34). Dentalni plak je 

mikrobni biofilm kojeg sačinjavaju mikroorganizmi 

normalne flore usne šupljine (34). Iako je 

dentalni plak najproširenija sesilna zajednica u 

ljudi, klinički se znakovi periodontitisa javljaju 

samo u onih kod kojih kronično prisustvo dentalnog 

plaka izaziva pojavu imunološkog odgovora 

i upale (35). To je uvjetovano osjetljivošću 

domaćina ili promjenom uvjeta u mikrookolišu 

usne šupljine (36). Osjetljivost domaćina 

određuju genetski i okolišni faktori, te stečene 

navike poput pušenja (35). Iako je upalni odgovor 

domaćina protektivan, destrukcija gingivalnog 

i periodontalnog tkiva može nastati ukoliko 

je preslabo ili prejako izražen (35). Destrukciji 

tkiva doprinosi i ekspresija faktora virulencije 

mikroorganizama u trenutku kada se, uslijed 

povećanog protoka tekućine u gingivalnim pukotinama 

i dotoka hranjivih tvari, te povišenja 

pH, mijenja mikrookoliš u oralnoj šupljini (34, 

36). Nastanak dentalnog plaka odvija se u tri 

koraka. Neposredno, nakon čišćenja površine 

zubi, izloženi dijelovi cakline bivaju obloženi 

proteinskim kondicionirajućim filmom, koji 

služi kao supstrat ranim bakterijskim kolonizatorima 

(1, 2, 37). Predominantni kolonizatori ranog 

biofilma su streptokoki (38), poput bakterija 

Streptococcus gordonii, S. sanguis, S. oralis, S. 

parasanguis i brojnih drugih (1, 38). Čimbenici 

koji favoriziraju streptokoke, kao inicijalne 

kolonizatore, jesu ekspresija adhezinâ koji prepoznaju 

receptore na kondicionirajućem filmu; 

sposobnost da, kao jedine izvore hranjivih tvari, 

metaboliziraju komponentne sline; te izrazita 

sposobnost intra- i inter-generičke koagregacije 

(38, 39). Procesom koagregacije, međustaničnog 

prepoznavanja i adherencije genetički različitih 

bakterija, te metaboličkim interakcijama drugih 

bakterija sa streptokokima, rani biofilm ubrzo 

postaje multigenerička mikrozajednica koju čine 

aerobne i aerotoleratne bakterijske vrste rodova 

Gemella, Actinomyces, Veillonella, Haemophilus, 

te Neisseria (38, 40). Skenirajućim elektronskim 

mikroskopom uspješno je prikazana dinamika 

stvaranja oralnog biofilma (39). Pojedinačne i 

manje nakupine stanica uočavaju se već nakon 

četiri sata, mikrokolonije nakon osam sati, a nakon 

12 sati na caklini se može uočiti monosloj 

bakterija. Ključnim posrednikom procesa koagregacije 

između ranih i kasnih kolonizatora u 

dentalnom plaku smatra se bakterija Fusobacterium 

nucleatum (41). Također se smatra kako 

ova gram-negativna bakterija promovira stvaranje 

anaerobnog mikrookoliša koji striktnoanaerobnim, 

kasnim kolonizatorima, omogućuje 

preživljavanje u aerobnoj atmosferi (41). Kasni 

kolonizatori su gram-negativne anaerobne bakterije, 

poput Porphyromonas gingivalis, Tanerella 

forsythensis i Treponema denticola (42). 

Apikalnom progresijom supragingivalnog plaka 

nastaje subgingivalni plak, a promjenom integriteta 

spojnog epitela dolazi do postepene kolonizacije 

površine zuba i stvaranja periodontalnog 

‘’džepa’’. U studijama bakterijske etiologije 

subgingivalnog biofilma, a time i periodontitisa, 

najčešće su bile korištene klasične metode kultivacije 

i molekularne identifikacijske metode, 

koje su, kao periodontalne patogene, identificirale 

proteolitičke vrste bakterija, koje su već 

navedene kao kasni kolonizatori dentalnog plaka 

(42). Kloniranjem i sekvencioniranjem gena 

bakterijske 16S rRNA u uzorcima subgingivalnog 

plaka osoba s periodontitisom, otkrilo se 

kako bakterije P. gingivalis, T. forsythensis i T. 

denticola čine tek manji dio zajednice, a kako 

dominiraju bakterije Peptostreptococcus sp. i 

Filifactor sp. Prevencija nastanka periodontitisa 

bazira se na kontroli nastanka oralnog biofilma, 

no za sada su se mehaničko odstranjivanje 

i kemijska kontrola pokazali neuspješnim (34). 

Nove strategije prevencije nastanka oralnog biofilma, 

poput interferencije transdukcije signala 

u biofilmu, modifikacije površine zubi, zamjena 

potencijalno patogenih s genetski modificiranim, 

manje virulentnim mikroorganizmima, te imunizacija, 

tek su početak nastojanja kontrole oralnog 

biofilma (34). Koja će od ovih strategija biti 

uspješna u prevenciji i kontroli oralnog biofilma 

pokazat će budućnost.

KRONIČNI OTITIS MEDIA 

Nakon obične prehlade, otitis media (OM) 

ili upala srednjeg uha, najčešći je razlog posjeta 

liječniku u dječjoj dobi. Do svoje treće godine 

života, gotovo 75% dječje populacije doživjet će 

najmanje jednu akutnu epizodu OM-a. Kronični 

OM dijeli se u dva podtipa - rekurentni (ROM) i 

eksudativni otitis media (eng. otitis media with 

effusion, OME) (43, 44). Dijagnoza rekurentnog 

OM-a postavlja se nakon tri ili više epizoda 

OM-a, tijekom šest mjeseci, između kojih nema 

kliničkih znakova bolesti (43, 44), a eksudativnog, 

ukoliko sekrecija perzistira duže od tri 

mjeseca (43). Kronični OM najčešći je uzrok 

provodnog oštećenja sluha u dječjoj dobi, što 

može imati za posljedicu otežan razvoj govora, 

a potom i socijalizacije djeteta (44). Primjena 

antimikrobnih lijekova u liječenju kroničnog 

OM-a, vrlo često rezultira terapijskim neuspjehom. 

Ukoliko eksudat u srednjem uhu perzistira 

dulje od šest tjedana, kirurškim se zahvatom 

u bubnjište postavlja cjevčica za kontinuiranu 

drenažu. Dugo vremena kronični OM smatrao se 

isključivo upalnim procesom usmjerenim spram 

zaostalih bakterijskih metabolita, a eksudat sterilnim 

(45). Tek od 1958. godine, otkrićem bakterija 

u eksudatu (43), patogeneza kroničnog OM-a 

objašnjava se bakterijskom infekcijom (46). 

Klasičnim metodama kultivacije u aspiratu eksudata 

srednjeg uha, tek u 20-40% slučajeva, može 

se dokazati bakterijski uzročnik kroničnog OM-a 

(43). Prema učestalosti, to su bakterije Haemophylus 

influenzae (8-20%), Streptococcus pneumoniae 

(4-10%) i Moraxella catarralis (2-8%), 

te manje zastupljeni patogeni, poput bakterija 

Staphylococcus aureus, Staphylococcus epidermidis, 

Streptococcus pyogenes i Pseudomonas 

aeruginosa (43, 46). Primjena visokoosjetljivih 

tehnika molekularne biologije, kao što je reakcija 

lančane polimeraze (engl. polymerase chain 

reaction, PCR), u detekciji bakterijske DNK tri 

najčešća patogena u aspiratu eksudata, rezultirala 

je pozitivnim nalazom u 80% slučajeva 

kroničnog OM-a (43, 44). Isprva velika razlika 

u detekciji uzročnika kroničnog OM-a klasičnim 

i PCR metodama, objašnjavala se činjenicom da 


početnice (engl. primer) korištene u PCR tehnologiji 

umnožavaju male bakterijske DNK fragmente, 

koji ne moraju nužno značiti prisutnost 

viabilnih mikroorganizama, već predstavljaju 

samo intaktne fragmente DNK uništenih bakterija 

ili ostatke patogena u uzorku (43, 47, 48). 

Ubrzo su uslijedila istraživanja koja su to opovrgla. 

Post i suradnici dokazali su, na animalnom 

modelu OM, da se pročišćena bakterijska DNK, 

te DNK toplinom inaktiviranih bakterija ne može 

detektirati dulje od tri dana u eksudatu bubnjišta 

(49). U istom je istraživanju uočeno da ubrzo, 

nakon primjene antimikrobnih lijekova, više nije 

moguće dokazati prisutnost uzročnika klasičnim 

metodama kultivacije, no PCR tehnologijom 

DNK patogena u uzorku može se detektirati i 

do tri tjedna nakon terapije (49). Slijedeći korak 

u istraživanjima bio je dokazivanje prisutnosti 

uzročnika u uzorcima. To je ostvareno detekcijom 

bakterijske glasničke ribonukleinske kiseline 

(mRNK) bakterije H. influenzae u uzorcima eksudata 

bubnjišta bolesnika s dijagnozom OME (50). 

Imajući na umu da je mRNK uzročnika infekcije 

molekula, čiji se životni vijek mjeri u sekundama 

i minutama, te da se sintetizira isključivo u intaknom 

mikroorganizmu, zaključeno je kako se u 

uzorku nalazi metabolički aktivan patogen (50). 

Nemogućnost uzgoja uzročnika klasičnim metodama 

kultivacije, te rezistencija pri primjeni antimikrobnih 

lijekova, rezultirala je postavljanjem 

hipoteze o bakterijskom biofilmu kao mogućem 

etiološkom faktoru u kroničnom OM-u. Koncept 

mukoznog biofilma zaživio je tek vizualizacijom 

sesilne zajednice na sluznici srednjeg 

uha, prvo na animalnim modelima (45, 51), a 

potom i na bioptatima sluznice djece s kroničnim 

OM-om (44). Istraživački tim američkog Centra 

za genomske znanosti (Center for Genomic Sciences, 

Pittsburgh, Pennsylvania), 2001. i 2002. 

godine, primjenom skenirajućeg elektronskog 

mikroskopa (SEM), detektirao je prisutnost bakterijskog 

biofilma na sluznici srednjeg uha, u prvom 

animalnom modelu, upotrijebivši u pokusu 

činčile (45, 51). Skenirajući uzorke elektronskim 

mikroskopom, pojava prvih mikrokolonija 

zamijećena je već 24 sata nakon indukcije eksperimentalnog 

OM-a, injiciranjem bakterije H. 

153

154 


influenzae u bubnjište činčila (45). Prisutnost biofilma 

detektirala se i 21. dan nakon inokulacije, 

a viabilnost bakterija, unutar biofilma, potvrdila 

primjenom CLSM-a i diferencijalnih vitalnih boja 

(45). Ubrzo je detektirano stvaranje biofilma, na 

životinjskom modelu, i pri injiciranju bakterije 

P. aeruginosa u bubnjište makaki majmuna (52). 

Nakon studija na animalnim modelima, 2006. 

godine, primjenom CLSM-a, dokazan je mukozni 

biofilm u 46 od 50 bioptičkih uzoraka sluznice 

srednjeg uha, djece s OME-om i rekurentnim 

OM-om (44). To je bio ključni dokaz da kronična 

infekcija srednjeg uha nije rezultat sterilnog upalnog 

procesa, već indolentne bakterijske infekcije, 

te da se neuspjeh antimikrobne terapije i obrane 

imunološkog sustava domaćina, može objasniti 

postojanjem biofilma u patogenezi ove bolesti. 

KRONIČNA PLUĆNA INFEKCIJA U BOLESNIKA S 

CISTIČNOM FIBROZOM 

Cistična fibroza (CF) je kronična, genetski 

uvjetovana, bolest donjeg respiratornog sustava. 

Godine 1989. otkriven je gen za cističnu fibrozu, 

a njegov produkt označen je kraticom CFTR 

(regulatorni protein transmembranskog prijenosa 

u cističnoj fibrozi). Ovaj regulatorni protein djeluje 

kao kloridni kanal u epitelnim stanicama respiratornog 

sustava. U bolesnika oboljelih od 

cistične fibroze, izrazito je oštećen transport kloridnih 

iona, što za posljedicu ima dehidraciju i 

zgušnjavanje sluzi koja normalno prekriva respiratorni 

epitel, te oštećenje mukocilijarnog sustava 

koji pomaže u odstranjivanju inhaliranih čestica. 

Oštećenje ovog primarnog neupalnog obrambenog 

mehanizma, dovodi do začepljenja malih 

dišnih puteva hiperviskoznom sluzi, sekundarne 

akutne ili kronične bakterijske infekcije, te aktivacije 

upalnog obrambenog mehanizma pluća 

(53, 54). U slučaju perzistencije infekcije, aktivacija 

PMN i oslobađanje njihove DNA, doprinosi 

viskoznosti sekreta u dišnim putevima, a 

stvaranje IgG protutijela rezultira nastankom 

imunokompleksa, koji oštećuju plućno tkivo (53, 

54). U najranijoj životnoj dobi, u ovih bolesnika, 

kao prvi kolonizatori dišnih puteva, dominiraju 

sojevi bakterija S. aureus i H. influenzae koji se, 

uz oštećeni mukocilijarni klirens, te povećanu 

ekspresiju receptora za bakterije na površini 

epitelnih stanica, smatraju predisponirajućim 

faktorima za kolonizaciju sojevima P. aeruginosa 

(3, 55). Prevalencija kolonizacije ovim oportunističkim 

patogenom, kod bolesnika odrasle 

dobi, gotovo je 80% (55). Dišni sustav, sinusi, te 

probavni trakt (pretpostavlja se uslijed gutanja 

sputuma), inicijalno se koloniziraju nemukoidnim 

sojevima P. aeruginosa, koji se tipično nalaze 

u okolišu (55). Interferencijom faktora virulencije 

(posebno toksina elastaze i alkalne proteaze) 

bakterije P. aeruginosa s nespecifičnom i 

specifičnom imunološkom obranom domaćina, 

početna intermitentna prelazi u perzistentnu kolonizaciju 

(55). Tijekom perzistentne P. aeruginosa 

kolonizacije, na bakterije djeluju dehidrirani 

i visokoosmolarni mikrookoliš u dišnom sustavu, 

te slobodni radikali kisika, nastali uslijed PMNodgovora 

na kolonizaciju, što rezultira promjenom 

nemukoidnog fenotipa sojeva u mukoidni, uslijed 

prekomjerne produkcije alginata (53-56). Alginat, 

nerazgranati, linearni egzopolisaharid, koji 

se sastoji od monomera manuronske i guluronske 

kiseline, glavna je komponenta matriksa 

mikrokolonija koje P. aeruginosa stvara u dišnim 

putevima, te jedini antigen ovog patogena, koji 

se izravno povezuje s lošom kliničkom prognozom 

kod ovih bolesnika (53, 55). Tranzicija sojeva 

u mukoidni fenotip povezuje se s indukcijom 

transkripcije algC, ključnog gena za 

biosintezu alginata, te inaktivacijskom mutacijom 

mucA gena, koji kodira antisigma faktor algT 

gena (1, 56). Posljedica mutacije mucA gena jeste 

porast razine sigma faktora, produkta algT gena, 

koji, za sada, nepoznatim mehanizmom, utječe 

na regulaciju sinteze flagela, što rezultira 

izostankom pokretljivosti bakterije (1, 56). Pojava 

mukoidnog fenotipa korelira s povećanim 

stvaranjem protutijela na gotovo sve antigene 

(uključujući i alginat) i toksine P. aeruginosa, te 

lošom kliničkom prognozom, što se povezuje s 

kroničnom upalnom reakcijom u kojoj dominiraju 

PMN, aktivacija komplementa i lokalna 

produkcija proupalnih citokina, te stvaranje imunokompleksa 

u kojima je glavni antigen lipopolisaharid 

(LPS) bakterijske stijenke (53, 55). U

prilog hipotezi da kronični endobronhiolitis, u 

bolesnika s CF-om, uzrokuje bakterija P. aeruginosa, 

koja stvara biofilm, govore elektronskomikroskopski 

prikazi mikrokolonija u sputumu 

bolesnika i uzorcima plućnog tkiva, uzetim prigodom 

autopsije (53, 56), te detekcija homoserinlaktonskih 

signalnih molekula u sputumu bolesnika 

(58). U proteklih desetak godina, bakterija P. 

aeruginosa postala je ogledni mikroorganizam za 

istraživanje biofilma i uočeno je kako formiranje 

biofilma varira s obzirom na raspoložive nutritivne 

izvore, te uvjete okoliša. Iako je model heterogenog 

biofilma trenutno prihvaćen kao model 

nastanka P. aeruginosa biofilma, sve je više 

istraživanja koja upućuju na potrebu nadopune 

ovog modela (58). Prema navedenom modelu, 

koji je uočen pri korištenju glukoze kao izvora 

ugljika, u adherenciji bakterija i stvaranju 

pojedinačnog sloja bakterija sudjeluju flagele, 

dok tip IV fimbrije omogućavaju kretanje bakterije 

po površini, te agregaciju stanica i stvaranje 

mikrokolonija, a na stvaranje gljivolikih 

višestaničnih zajednica, u procesu maturacije, 

utječe detekcija kvoruma (58). Korištenjem citrata, 

kao izvora ugljika, uočeno je da P. aeruginosa 

stvara ravan biofilm, koji se bitno razlikuje 

od prethodno opisanog heterogenog modela (58). 

U ovom alternativnom modelu, flagele nisu sudjelovale 

u adherenciji bakterija za supstrat, 

mikrokolonije su nastale klonalnim rastom jedne 

stanice, a kretanje posredovano tip IV fimbrijama 

rezultiralo je širenjem bakterija duž supstrata, uz 

izostanak većih mikrokolonijskih struktura (58). 

Nedavno je iz soja 57RP P. aeruginosa biofilma, 

izolirana i visokoadherentna, mala fenotipska 

varijanta, sa prekomjerno izraženim fimbrijama, 

koja ima povećane sposobnosti stvaranja biofilma 

(59). Premda se u kronično inficiranih CF 

bolesnika susreće jedan ili tek nekoliko genotipova 

P. aeruginosa, značajne fenotipske varijabilnosti 

izolata rezultat su učestalih promjena 

okoliša u plućima bolesnika, te odgovora ove 

bakterije na te promjene fenotipskom adaptacijom 

(59, 60). Otkrivanje mehanizama koji 

omogućuju fenotipsku adaptaciju, te daljnje 

istraživanje stvaranja biofilma u kronično inficiranih 

bolesnika, povezuje se s uspješnijom 


kontrolom i eradikacijom infekcije u oboljelih. U 

kronično inficiranih bolesnika s CF-om, trajna 

eradikacija P. aeruginosa gotovo je nedostižan 

cilj, pa su potrebne druge kratkotrajne i prijelazne 

terapijske mjere s ciljem smanjenja broja bakterija 

u sputumu, poboljšanja funkcije pluća, te 

odgađanja nepovratnih oštećenja plućnog tkiva 

(55). Dugotrajna perzistencija P. aeruginosa, te 

rezistencija na primjenu antimikrobnih lijekova u 

bolesnika s CF-om, pripisuje se mutacijama bakterija 

i izmjeni genskog materijala koji doprinose 

rezistenciji na lijekove, smanjenoj djelotvornosti 

lijekova u anaerobnim uvjetima, te biofilmspecifičnim 

mehanizmima rezistencije (61). 

Nemogućnost trajne eradikacije i rezistencija patogena 

naglašavaju potrebu za prevencijom ili 

odgodom uspostavljanja kronične infekcije već u 

fazi intermitentne kolonizacije ranom i agresivnom 

antimikrobnom terapijom (55). Terapijske 

mjere, poduzete nakon inicijalnog izoliranja 

P. aeruginosa, poput inhalacija kolistina ili tobramicina, 

te oralne primjene ciprofloksacina, uz 

kohortnu izolaciju bolesnika, pokazale su se 

uspješnim u prevenciji i epidemiologiji kronične 

P. aeruginosa infekcije (62). Nove spoznaje rezultirale 

su promjenom terapijskog pristupa u 

kroničnoj infekciji, pa je prethodna terapija samo 

akutnih egzacerbacija kronične infekcije zamijenjena 

kroničnom supresivnom kemoterapijom 

kojom se nastoji smanjiti broj i aktivnost bakterije 

P. aeruginosa u plućima bolesnika s ciljem 

poboljšanja plućne funkcije (53). Iako mehanizam 

djelovanja antimikrobnih lijekova u 

kroničnoj infekciji povezanoj s biofilmom nije 

razjašnjen, in vitro se primjenom kombinacije 

β-laktama i aminoglikozida, najčešće korištenih 

antipseudomonasnih lijekova, uočilo smanjenje 

broja bakterija u sesilnoj zajednici na svega 20%, 

a pri primjeni pojedinih antibiotika u subinhibicijskim 

koncentracijama (subMIK), supresija 

stvaranja proteaze, fosfolipaze C, te alginata u P. 

aeruginosa (53, 63). Antimikrobna terapija rezultira 

smanjenjem prisutnosti bakterijskih antigena, 

a time i imunološki uzrokovanog oštećenja 

plućnog tkiva (53). Rezultati novijih istraživanja 

pokazali su djelotvornost makrolida u biofilm infekcijama 

uzrokovanih bakterijom P. aeruginosa, 

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156 


što se povezuje s njihovom protuupalnom 

aktivnošću, te subMIK učinkom, poput inhibicije 

adherencije, pokretljivosti bakterije, te detekcije 

kvoruma (64-66). Istraživanjima kronične P. aeruginosa 

infekcije u bolesnika s cističnom fibrozom, 

nastoji se otkriti učinkovita terapija koja bi 

prevenirala nastanak ili omogućila uništenje biofilma 

u ovih bolesnika. 

KRONIČNI CISTITIS 

Infekcije mokraćnog sustava (IMS), nakon 

respiratornih, druge su po učestalosti bakterijske 

infekcije. Većina se ovih infekcija javlja kod 

mladih i zdravih žena. Gotovo 80% žena svjetske 

populacije, tijekom svoga života, ima najmanje 

jednu IMS, a 27-44% ovih bolesnica, unutar 

slijedećih šest mjeseci, ima i rekurentnu 

epizodu bolesti, unatoč antimikrobnoj terapiji 

(67, 68). U gotovo 80% slučajeva IMS-a kao 

uzročnik se izolira uropatogena Escherichia coli 

(UPEC) (68, 69). Bakterijski biofilm ima važnu 

ulogu u patogenezi, perzistenciji i terapiji infekcija 

mokraćnog sustava. Naime, stvaranje biofilma 

u mokraćnom sustavu povezuje se s 

kroničnim cistitisom, te struvitnom urolitijazom. 

U posljednje tri godine intenzivno se proučava 

povezanost progresije IMS-a u perzistentnu UP- 

EC-induciranu infekciju, u nekoliko in vitro i 

animalnih in vivo modela (68, 70-72). Kao 

ključni faktor uspostavljanja biofilma uropatogene 

E. coli na abiotičkim površinama, u stacionarnim 

uvjetima i uvjetima hidrodinamičkog 

protoka, te luminalnoj površini mišjeg mokraćnog 

mjehura, smatra se FimH adhezin, koji se nalazi 

na vrhu tipa 1, manoza-senzitivnih fimbrija (71, 

72). Ovaj adhezin veže manozilirane ostatke na 

integralnim membranskim proteinima, uroplakinima 

(UP), koji su izraženi na luminalnoj strani 

superficijalnih epitelnih stanica mokraćnog mjehura 

(70). Udruživanjem četiri poznata UP molekula 

(UP Ia, Ib, II i III) nastaju heksamerni prsteni, 

a organizacijom prstena nastaju kristalni 

plakovi, koji prekrivaju gotovo cijelu luminalnu 

površinu mokraćnog mjehura sa zadaćom 

očuvanja integriteta epitelne membrane, te stvaranja 

kemijski nepropusnog sloja za difuziju u 

epitel (70). U mišjem modelu cistitisa, primjenom 

skenirajućeg i transmisijskog elektronskog 

mikroskopa, zamijećeno je da, jedan do tri sata 

nakon adheriranja bakterije na površinu epitelnih 

stanica, dolazi do brzog prodora UPEC-a u 

epitelne stanice. Prodor bakterije u stanicu posredovan 

je FimH adhezinom koji otpočinje signalnu 

kaskadu u domaćinovim epitelnim stanicama, 

što rezultira lokaliziranim preslagivanjem 

aktina, te uvlačenjem adherirane bakterije u stanicu 

zatvaranjem membrane oko mikroorganizma 

(68, 70, 72). Nakon invazije u superficijalne 

epitelne stanice mokraćnog mjehura, UPEC se 

ubrzano dijeli u citoplazmi, te u narednih osam 

sati, stvara slabo povezane, male nakupine bakterija, 

koje zadržavaju tipičnu morfologiju 

štapića (68, 70, 71). Uspostavljanjem ovih ranih 

intracelularnih bakterijskih zajednica (IBZ), 

bakterija stvara protektivni okoliš u kojem je 

zaštićena od djelovanja antimikrobnih lijekova, 

te domaćinova imunološkog odgovora (68, 70). 

Šest do osam sati nakon infekcije, dolazi do 

dramatične fenotipske promjene IBZ-a, te rana 

IBZ sazrijeva u zajednicu nalik na biofilm (70, 

71). Bakterije u biofilmu poprimaju kokoidni 

oblik i ispunjavaju cijelu superficijalnu epitelnu 

stanicu; brzina rasta bakterija usporava na više 

od jednog sata, male nakupine bakterija povezuju 

se u gustu organiziranu zajednicu globularnog 

izgleda (70, 71). U ovom stadiju, bakterije na 

svojoj površini imaju izražena brojna amiloidna 

vlakna, koja omogućavaju stvaranje individualnog 

odjeljka za svaku bakteriju, te površinske 

molekule, poput tip 1 fimbrija i antigena 43, koje 

doprinose interakcijama, tijekom stvaranja 

mikrokolonija (68, 70). Ključni proces maturacije 

intracelularnog biofilma, koji tvori E. coli, 

jeste sekrecija kolanske kiseline, egzopolisaharida 

koji stvara polisaharidni matriks oko bakterijskih 

stanica (68, 70). Vizualizacijom ovog stadija 

infekcije, na površini inficiranog mišjeg 

mokraćnog mjehura, uočene su brojne protruzije, 

nastale uslijed utjecaja mase bakterijskog biofilma 

na staničnu membranu superficijalnih 

epitelnih stanica (68, 71). Dvanaest sati nakon 

infekcije, kokoidne bakterije, na površini IBZ-a, 

ponovo poprimaju morfologiju štapića, postaju

izrazito pokretne, te se odvajaju iz bakterijskog 

biofilma (71). U trenutku kada stignu do ruba 

stanice domaćina, ove bakterije izbijaju kroz 

staničnu membranu, te prodiru u lumen 

mokraćnog mjehura procesom koji se naziva 

izlijevanje (71). Narušavanjem integriteta 

domaćinove stanične membrane, ubrzo se, nakon 

ovih pojedinačnih stanica, u lumenu 

mokraćnog mjehura pojavljuju bakterije iz 

mnogobrojnih IBZ-a, što rezultira oslobađanjem 

miliona UPEC, pojave bakteriurije, te širenja i 

kolonizacije novih superficijalnih epitelnih stanica 

(70, 71). U lumenu mokraćnog mjehura, 

bakterije, oslobođene iz biofilma, diferenciraju 

se u 70 µm duge filamentozne tvorbe (71). Iako 

je mehanizam i svrha nastanka filamenata do 

danas nepoznata, pretpostavlja se da, na taj 

način, UPEC preživljava napad imunološkog 

sustava domaćina dovoljno dugo da septacijom 

filamenata nastane nova populacija bakterija, 

koja započinje slijedeći ciklus invazije i stvaranja 

IBZ-a u do tada neinficiranim superficijalnim 

epitelnim stanicama (68, 71). U nekoliko 

slijedećih postinokulacijskih dana, bakterije 

prolaze kroz višestruke cikluse stvaranja IBZ-a, 

no, sa svakim novim ciklusom, vrijeme koje je 

potrebno da IBZ prođe kroz sva četiri fenotipa 

intracelularnog biofilma, sve je sporije i sporije 

(68). U konačnici se, unutar superficijalnih 

epitelnih stanica, uočavaju samo male nakupine 

štapićastih bakterija, koje ulaze u stanje mirovanja, 

tzv. dormant fazu (68). U fazi mirovanja, 

UPEC može perzistirati u mokraćnom mjehuru 

mjesecima nakon inicijalne infekcije (68). 

Zahvaljujući IBZ koja je nalik na biofilm, UPEC 

uspješno odolijeva nespecifičnom imunološkom 

odgovoru domaćina (70, 71). Naime, lipopolisaharidi 

stanične stijenke UPEC-a aktiviraju Tollnalik 

receptore tipa 4 na membrani superficijalnih 

epitelnih stanica, što rezultira oslobađanjem 

upalnih citokina i masivnom infiltracijom 

mokraćnog mjehura polimorfonuklearnim leukocitima 

(PMN) (68). Iako u mokraćnom mjehuru, 

u fazi nastanka rane IBZ, polimorfonukleari 

migriraju prema inficiranim stanicama i 

pokušavaju prodrijeti u intracelularni biofilm, a 

kasnije pokušavaju uništiti filamentozne oblike 


bakterija, njihovo djelovanje na UPEC je bez uspjeha 

(68, 71). Osim aktivacije PMN, infekcija 

inducira i masivnu eksfolijaciju superficijalnih 

epitelnih stanica, no odljuštenje stanica u lumen 

mokraćnog mjehura rezultira samo smanjenjem 

broja bakterija, a ne i uništenjem IBZ (70). Ako 

odolijevanju imunološkom odgovoru domaćina 

pridodamo i rezistenciju biofilma na antimikrobnu 

terapiju, jasno je da sposobnost stvaranja 

IBZ-a omogućuje uropatogenoj E. coli iznimno 

dugu perzistenciju u mokraćnom mjehuru, a time 

i mogućnost nastanka kroničnih rekurentnih infekcija 

(68). Nakon mišjeg modela infekcije, kojim 

je pokazano značenje biofilma u patogenezi 

IMS-a, slijedećim studijama predstoji dokazati 

postojanje IBZ-a u bolesnika s rekurentnim cistitisom. 

Uz kronični cistitis, bakterijski se biofilm 

povezuje i s patogenezom stuvitne uro/nefrolitijaze. 

Struvitni kamenci nastaju kao 

posljedica bakterijske IMS, te premda čine svega 

10-20% svih kamenaca u mokraćnom sustavu, 

predstavljaju pravi izazov u liječenju, uslijed 

brzog rasta i rekurencije koja se javlja u gotovo 

50% slučajeva ove bolesti (73). Ključni faktori 

virulencije bakterija, uključeni u stvaranje kamenaca, 

jesu produkcija metaloenzima ureaze i 

bakterijski egzopolisaharidi (73, 74). Enzim ureaza 

hidrolizira ureu, koja je u urinu prisutna u 

velikim količinama, pri čemu nastaje amonijak i 

ugljični dioksid. Tako stvoreni amonijak podiže 

pH urina, uslijed čega topivi ioni magnezija i kalcija 

precipitiraju, te nastaju kamenci koji sadrže 

magnezij amonij fosfat (struvit) i kalcij fosfat 

(apatit) (74). Bakterijski egzopolisaharidi doprinose 

stvaranju kamenaca ubrzavanjem supersaturacije 

i kristalizacije iona kalcija i magnezija 

elektrostatskim interakcijama, te vezivanjem 

ovih iona za anionske grupe na njihovoj površini 

(73). Uzročnik koji, uz ostale, posjeduje oba 

navedena faktora virulencije i koji se najčešće 

povezuje s nastankom stuvitnih kamenaca jeste 

bakterija Proteus mirabilis. Pretpostavljalo se 

da, u procesu nukleacije kristala i nastanka kamenaca, 

ključnu ulogu ima sposobnost bakterija 

da stvaraju biofilm, pri čemu bi izvanstanični 

polisaharidni matriks biofilma promovirao 

vezivanje kristala (75). To je potaklo istraživače 

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158 


da u studijama povezanosti bakterija sa struvitnim 

kamencima, primjene morfološke tehnike 

moderne mikrobiologije, poput skenirajućeg i 

transmisijskog elektronskog mikroskopa. Ovim 

je tehnikama tako dokazana prisutnost bakterija 

u obliku mikrokolonija, unutar glikokaliksa intersticija, 

jezgre i površine struvitnih kamenaca, 

kirurški odstranjenih iz bolesnika (76), te infekcijom 

induciranih u animalnim modelima (štakor, 

miš) (74, 77). Odolijevanje djelovanju antimikrobnih 

lijekova i obrani imunološkog sustava 

domaćina objašnjava se pozicioniranjem 

bakterija duboko u matriksu kamenca, odnosno 

stvaranjem sesilne zajednice, ukoliko se nalaze 

na njegovoj površini (74). Sve to doprinosi perzistenciji 

infekcije, daljnjem rastu struvitnih kamenaca, 

čestim rekurentnim infekcijama, te 

teškim oštećenjima, osobito bubrega. Danas se u 

terapiji struvitnih kamenaca upotrebljava mrvljenje 

kamenaca udarnim valovima ili perkutana 

nefrolitotomija, odnosno ureteroskopija, no u 

budućnosti se očekuje primjena lijekova koji 

penetriraju u biofilm kamenaca i uništavaju ga, 

te primjena inhibitora ureaze (78). 

KRONIČNI PROSTATITIS 

Prostatitis, upala prostate, najčešći je urološki 

problem kod muškaraca mlađih od 50 godina, te 

treći po učestalosti klinički entitet kod muškaraca 

starije životne dobi. Primjenom indeksa simptoma 

kroničnog prostatitisa (engl. Chronic Prostatitis 

Symptom Index, CPSI), razvijenog od 

strane američkog Nacionalnog instituta za zdravlje 

(NIH), kod muškaraca, u dobi od 20. do 74. 

godine, nađena je 10% prevalencija simptoma 

prostatitisa (79). Sve do 1995. godine, kada je u 

Bethesdi, pod pokroviteljstvom NIH-a, donešena 

nova klasifikacija (80), prostatitis se klasificirao 

u četiri klinička entiteta: akutni i kronični bakterijski 

prostatitis, nebakterijski prostatitis i prostatodinija. 

U novoj su klasifikaciji prve dvije 

kategorije ostale iste, no preostala dva klinička 

entiteta objedinjena su u kategoriju III – kronični 

abakterijski prostatitis/kronična bol u zdjelici 

(81). Ova kategorija, s obzirom na prisutnost ili 

odsutnost upalnih stanica u uzorcima specifičnim 

za prostatu (eksprimat prostate i prvi mlaz urina 

nakon masaže prostate) (80), dodatno se dijeli 

na upalnu (IIIA) i neupalnu (IIIB) potkategoriju. 

Novost spram stare klasifikacije jeste i kategorija 

IV, u koju ulaze bolesnici bez simptoma i dijagnoze 

prostatitisa, a kod kojih je biopsijom prostate 

ili u specifičnim uzorcima detektirana prisutnost 

upale i/ili mikroorganizama (80). Kronični 

bakterijski prostatitis karakteriziraju rekurentne 

infekcije mokraćnog sustava, s nespecifičnim 

simptomima između simptomatskih infekcija, 

te perzistencija bakterija u prostati usprkos 

višestruko provedenim antimikrobnim terapijama 

(82). Najčešći uzročnici prostatitisa jesu dobro 

poznati gram-negativni uropatogeni poput bakterija 

E. coli (u gotovo 80% slučajeva), Klebsiella 

sp., Serratia sp., Enterobacter sp. i P. aeruginosa. 

Gram-pozitivne bakterije, izuzev bakterije Enterococcus 

faecalis, koja se smatra uzročnikom 

kroničnog bakterijskog prostatitisa, imaju vrlo 

upitnu ulogu u mikrobnoj etiologiji prostatitisa 

(80). Kada uzročnici uđu u kanaliće i acinuse 

prostate, ascenzijom iz mokraćne cijevi i/ili povratom 

urina u prostatične kanaliće (75), ondje se 

ubrzano razmnožavaju i izazivaju akutni upalni 

odgovor domaćina. Vitalne i umiruće bakterije, i 

stanice akutne upale, deskvamirane epitelne stanice 

i stanični detritus, ispunjavaju kanaliće, no sve 

dok je infekcija u akutnoj fazi, odgovarajućom 

antimikrobnom terapijom, moguće je eradicirati 

planktonske uzročnike, te suzbiti upalni proces 

(75). Pri subakutnoj upali ili perzistenciji bakterija 

unutar opstruiranih prostatičnih kanalića, bakterije 

mogu adherirati na epitel stijenki kanalića i 

ubrzo stvoriti sporadične mikrokolonije biofilma, 

što može dovesti do perzistentne stimulacije 

imunološkog sustava i posljedično kronične upale 

(75). Premda je klasična kvantitativna kultivacija 

uzoraka urina i eksprimata prostate ključna 

za dijagnozu kroničnog prostatitisa, kada se radi 

o mikrobiološkoj dijagnostici kliničkih entiteta u 

kategoriji III i IV, to je onda pravi klinički izazov 

(75). Neuspjeh detekcije bakterija kultivacijom 

u ovih bolesnika objašnjava se prisutnošću/ 

odsutnošću inhibitornih tvari u sekretima prostate, 

poput visoke koncentracije cinka i prostatičnog 

antibakterijskog faktora, te planktonskih bak-

terija u uzorcima (80, 83). Naime, planktonske 

se stanice teško odvajaju od sesilne zajednice i 

bivaju eradicirane primjenom empirijske antimikrobne 

terapije (80). Da antimikrobna terapija 

ne utječe na biofilm, te da bakterijske stanice 

perzistiraju u prostati, ubrzo je potvrđeno detekcijom 

mikroorganizama u bioptičkim uzorcima 

prostate u bolesnika, te elektronsko-mikroskopskim 

prikazom egzopolisaharidom prekrivenih 

mikrokolonija čvrsto adheriranih bakterija za 

stijenke kanalića i acinusa (84). Novi koncept 

mikrobiološke etiologije kroničnog prostatisa 

rezultirao je primjenom molekularnih tehnika u 

studijama prostatitisa. Primjenom PCR metode, 

detektirana je prisutnost 16S rRNA bakterija u 

77% bioptičkih uzoraka prostate (83), a potom u 

65% uzoraka eksprimata prostate u oboljelih od 

kroničnog prostatitisa (85). Ubrzo se postavilo 

pitanje jesu li detektirani mikroorganizmi doista 

i uzročnici kroničnog prostatitisa. Prvi dokaz dobiven 

je usporedbom PCR rezultata dobivenih 

iz uzoraka prostatičnog tkiva zdravih donora 

prostate i bolesnika koji su bili podvrgnuti prostatektomiji 

(86). Dok su u grupi zdravih donora, 

u svim uzorcima PCR-a, rezultati bili negativni, 

te znakovi upale odsutni, u grupi oboljelih od 

karcinoma prostate i benigne hipertrofije prostate 

(BHP), u 70% uzoraka, dokazana je prisutnost 

upale i dobiven pozitivan PCR rezultat. Imajući 

na umu da gotovo 90% bolesnika s BHP-om ima 

prostatitis (86), te da prisutnost upalnih stanica u 

uzorku bioptata prostate dobro korelira s detekcijom 

bakterijskih genskih sekvenci (83), može 

se zaključiti da su detektirani mikroorganizmi 

ujedno i uzročnici prostatitisa. Bakterijski biofilm 

utječe i na rezultate primjene antimikrobne 

terapije u sindromu kroničnog prostatitisa. Iako 

se u početku smatralo da kronični upalni proces 

u prostati mijenja farmakokinetska svojstva antimikrobnih 

lijekova (87) i utječe na terapijski 

uspjeh, studijama na animalnom modelu to nije 

potvrđeno. Danas se nemogućnost eradikacije 

bakterija u kroničnom prostatitisu objašnjava 

sesilnim načinom života bakterija u prostati, te 

intrizičnom rezistencijom biofilma (75). Primjena 

molekularnih tehnika u detekciji i elektronskog 

mikroskopa u vizualizaciji, omogućili su pov- 


ezivanje biofilma s etiologijom kroničnog prostatitisa, 

a rezultati daljnjih istraživanja trebali bi 

unaprijediti terapijski pristup ovom sindromu. 

KRONIČNE INFEKCIJE RANA 

Vrlo općenito, rane, prema njihovoj etiologiji, 

dijele se na akutne i kronične. Dok akutne 

rane uzrokuje eksterno oštećenje intaktne kože, 

kronične rane nastaju endogenim mehanizmima 

koji su povezani s predisponirajućim stanjima, 

poput metaboličke bolesti ili oštećenja arterijskog, 

odnosno venskog protoka, uslijed čega dolazi do 

oštećenja integriteta dermalnog i epidermalnog 

tkiva (88). Osim s kolonizacijom, prisutnost bakterija 

u akutnim i kroničnim ranama, povezuje se 

s razvojem upale, a time i procesom cijeljenja, 

invazivnim infekcijama i sepsom, zatajenjem organa, 

pa i smrtnim ishodom. Premda se u brojnim 

studijama mikroorganizmi, poput bakterija S. aureus, 

P. aeruginosa, te β-hemolitički streptokoki, 

najčešće povezuju s odgođenim cijeljenjem i infekcijom 

rana, u većini rana nalazi se polimikrobna, 

aerobna i anaerobna flora (88, 89). Zbog perzistencije 

infekcije, te rezistencije na sistemske i 

topičke antimikrobne lijekove, posljednjih godina 

pretpostavlja se kako bakterije koje koloniziraju 

kronične rane tvore sesilnu zajednicu, odnosno 

biofilm (90, 91). Sklonost bakterijskoj kontaminaciji, 

dostupnost supstrata, te izrazito velika 

površina koja podržava adherenciju bakterija, 

čini kronične rane gotovo idealnim okolišom za 

stvaranje biofilma (90). No, direktni dokazi koji bi 

podržali značenje biofilma u patogenezi kroničnih 

rana za sada su rijetki. Prvi pokušaji vizualizacije 

formiranja biofilma u kroničnim ranama temeljili 

su se na primjeni modificirane Kongo-red tehnike 

bojanja za prikaz polisaharida. Primjenom 

navedene tehnike u in vitro modelu P. aeruginosa 

biofilma, uočeno je kako je bakterijama, iz uzoraka 

rana ljudi s opeklinama, dovoljno tek sedam 

do deset sati za stvaranje zrelog biofilma (92). 

Nakon in vitro modela, ista grupa autora dokazala 

je postojanje biofilma i u ranama svinjskog 

in vivo modela (90). Uslijedio je i prikaz S. aureus 

biofilma u akutnim ranama pomoću skenirajuće 

elektronske mikroskopije (93), a naposljetku 

159

160 


istraživači američkog Centra za inžinjering biofilma 

Sveučilišta u Montani dokazali su i prisutnost 

biofilma u 60% uzoraka kroničnih rana 

(94). Upravo se stvaranje biofilma u kroničnim 

ranama smatra najboljim objašnjenjem zatajenja 

procesa cijeljenja takvih rana. Na cijeljenje rane 

i tijek infekcije utječe bakterijska sposobnost 

stvaranja stabilne, sesilne zajednice, te sposobnost 

domaćinova imunološkog sustava da kontrolira 

infekciju (91). Zajednice mikroorganizama 

mogu na proces cijeljenja utjecati direktno, 

produkcijom destruktivnih enzima i toksina, ili 

indirektno, promoviranjem stanja kronične upale 

u kojem oslobađanje slobodnih radikala i brojnih 

litičkih enzima negativno utječe na proliferaciju 

stanica, a time i na proces cijeljenja rane (91). 

Nadalje, djelovanje biofilma na proces cijeljenja 

objašnjava se njegovom smanjenom osjetljivošću 

na imunološki obrambeni odgovor domaćina. 

Poznato je da matriks biofilma inhibira kemotaksiju 

i degranulaciju PMN-a i makrofaga, te da PMN 

ne uspijevaju fagocitirati bakterije unutar biofilma. 

To PMN potiče na oslobađanje velike količine 

proupalnih enzima i citokina, te metaloproteaza 

matriksa (95, 96). Posljedice povišene razine endogenih 

metaloproteaza matriksa, te nestanka njihovih 

prirodnih inaktivatora u kroničnim ranama, 

jesu mnogobrojne. Proteolitičkim djelovanjem 

ovih enzima smanjuje se razina faktora rasta i 

citokina koji reguliraju pokretanje i rast stanica 

poput keratinocita, fibroblasta i stanica endotela, 

a dolazi i do nekontrolirane destrukcije ekstracelularnog 

matriksa koji, osim što koži daje snagu i 

otpornost, čini osnovu za prerastanje epidermisa 

i rast krvnih žila i živaca (96). Kako svaki od 

navedenih faktora sudjeluje u procesu cijeljenja 

u točno određenom trenutku, izostanak normalna 

slijeda događaja rezultira zaustavljanjem kronične 

rane u fazi upale i stvaranja granulacijskog tkiva. 

Dokazana prisutnost biofilma u kroničnim 

ranama i njegova povezanost s procesom cijeljenja 

motivirala je istraživače na razmatranje 

novih strategija kontrole biofilma. Jedna od ideja 

temelji se na prevenciji razvoja bakterijskog biofilma 

posredstvom komponente nespecifične imunosti 

– laktoferina (97, 98). Laktoferin je glikoprotein 

sa sposobnošću vezivanja željeza, koji, 

pri koncentracijama nižim od onih potrebnih za 

uništenje ili prevenciju rasta bakterija, stimulira 

specijalni oblik kretanja bakterije na površini supstrata, 

te na taj način onemogućuje adherenciju i 

stvaranje mikrokolonija i nakupljanje (97, 98). 

Stoga se pretpostavlja da bi preparati laktoferina 

mogli razoriti već postojeći biofilm, što bi utjecalo 

na zaštitu kronične rane od infekcije. Druga 

mogućnost kontrole stvaranja biofilma jeste interferencija 

s detekcijom kvoruma. Poznato je 

da gram-negativne bakterije, kao signalne molekule, 

koriste AHL, a gram-pozitivne cikličke peptide 

(4). Proučavanjem strukture ovih signalnih 

molekula, te stvaranja, širenja i primanja signala, 

istraživači su, u potrazi za mogućnostima inhibicije 

detekcije kvoruma, pronašli brojne molekule 

s agonističkim, antagonističkim ili enzimskim 

djelovanjem na AHL, kao što su supstance 

nekih biljaka i gljiva koje interferiraju s AHLposredovanom 

komunikacijom, te halogenirane 

tvari furanona koje utječu na ekspresiju gena koji 

kontroliraju detekciju kvoruma i povećavaju osjetljivost 

biofilma na antimikrobne lijekove (4). 

Smatra se kako farmakološka inhibicija detekcije 

kvoruma pruža novu nadu u kontroli bakterijskog 

biofilma brojnih infekcija, pa tako i one u 

kroničnim ranama. 

Zaključak 

Svakako, nužni su novi terapijski pristupi 

koji bi omogućili uspješno liječenje biofilminfekcija. 

Potencijalna terapija, uz primjenu 

inhibitora detekcije kvoruma i činitelja virulencije 

bakterija, uključuje i enzimsku razgradnju ili 

oštećenje izvanstaničnog matriksa biofilma, što 

bi za posljedicu imalo disperziju biofilma, a time 

i smanjenje njegove rezistencije na djelovanje 

imunološkog sustava domaćina i antimikrobnih 

lijekova (99). Johansen i suradnici dokazali 

su baktericidnu aktivnost oksidoreduktaza, te 

učinak primjene enzima koji hidroliziraju polisaharide 

na uništenje bakterijskog biofilma koji 

tvore bakterije S. aureus, S. epidermidis, P. aeruginosa 

i Pseudomonas fluorescens sa abiotičkih 

supstrata (100). Nedavno je francuska grupa 

istraživača uočila uspjeh u primjeni disperzina B,

enzima koji hidrolizira poli-N-acetilglukozamin, 

u kombinaciji s proteazama u eradikaciji biofilma 

različitih stafilokoknih sojeva (101). Liječenje 

kroničnih infekcija mora počivati na spoznajama 

LITERATURA 

1. Davey ME, O’Toole GA. Microbial biofilms: 

from ecology to molecular genetics. Microbiol 

Mol Biol Rev 2000; 64:847-67. 

2. Donlan RM. Biofilms: microbial life on surfaces. 

Emerg Infect Dis 2002; 8:881-90. 

3. Donlan RM, Costerton JW. Biofilms: survival 

mechanisms of clinically relevant microorganisms. 

Clin Microbial Rev 2002; 15:167-93. 

4. Hentzer M, Givskov M. Pharmacological inhibition 

of quorum sensing for the treatment of 

chronic bacterial infections. J Clin Invest 2003; 

112:1300-7. 

5. Greenberg EP. Bacterial communication and 

group behavior. J Clin Invest 2003; 112:1288-90. 

6. Marić S, Vraneš J. Characteristics and significance 

of microbial biofilm formation. Period Biolog 

2007; 109:115-21. 

7. Gieseke A, Purkhold U, Wagner M, Amann R, 

Schramm A. Community structure and activity 

dynamics of nitrifying bacteria in a phospateremoving 

biofilm. Appl Environ Microbiol 2001; 

67:1351-62. 

8. Macedo AJ, Kuhlicke U, Neu TR, Timmis KN. 

Abraham WR. Three stages of a biofilm community 

developing at the liquid-liquid interface between 

polychlorinated biphenyls and water. Appl 

Environ Microbiol 2005; 71:7301-9. 

9. Chenier MR, Beaumier D, Roy R, Driscoll BT, 

Lawrence JR, Greer CW. Influence of nutrients, 

hexadecane, and temporal variations on nitrification 

and exopolysaccharide composition of river 

biofilms. Can J Microbiol 2006; 52:786-97. 

10. Chenier MR, Beaumier D, Fortin N, Roy R, Driscoll 

BT, Lawrence JR, Greer CW. Influence of 

nutrient inputs, hexadecane, and temporal variations 

on denitrification and community composition 

of river biofilms. Appl Environ Microbiol 

2006; 72:575-84. 

11. Satoh H, Yamakawa T, Kindaichi T, Ito T, Okabe 

S. Community structures and activities of nitrifying 

and denitrifying bacteria in industrial wastewater-treating 

biofilms. Biotechnol Bioeng 2006; 

94:762-72. 

12. Vinarov A, Robysheva Z, Sokolov D, Smirnov 

V. Examination of the long-term process for purifying 

gaseous discharges in industrial biofilter. 

Commun Agric Appl Biol Sci 2003; 68:211-3. 


o karakteristikama, organizaciji i funkcioniranju 

biofilma, kao cjelovite multicelularne strukture u 

određenoj kroničnoj infekciji, a ne biti usmjereno 

na pojedinačne mikroorganizme kao do sada. 

13. Valenzuela L, Chi A, Beard S, Orell A, Guiliani 

N, Shabanovitz J, Hunt DF, Jerez CA. Genomics, 

metagenomics and proteomics in biominimg 

microorganisms. Biotechnol Adv 2006; 24:197- 

211. 

14. Olson ME, Ceri H, Morck DW, Buret AG, Read 

RR. Biofilm bacteria: formation and comparative 

susceptibility to antibiotics. Can J Vet Res 2002; 

66:86-92. 

15. Coetser SE, Cloete TE. Biofouling and biocorrosion 

in industrial water systems. Crit Rev Microbiol 

2005; 31:213-32. 

16. Neria-Gonzales I, Wang ET, Ramirez F, Romero 

JM, Hernandez-Rodriguez C. Characterization of 

bacterial community associated to biofilms of corroded 

oil pipelines from the southeast of Mexico. 

Anaerobe 2006; 12:122-33. 

17. Smith JL, Fratamico PM, Novak JS. Quorum 

sensing: a primer for food microbiologists. J Food 

Prot 2004; 67:1053-70. 

18. Ekman J, Kosonen M, Jokela S, Kolari M, Korhonen 

P, Salkinoja-Salonen M. Detection and 

quantification of colored deposit-forming Meiothermus 

spp. in paper industry processes and 

end products. J Ind Microbiol Biotechnol 2007; 

34:203-11. 

19. Beech IB, Sunner JA, Arciola CR, Cristiani P. 

Microbially-influenced corrosion: damage to 

prostheses, delight for bacteria. Int J Artif Organs 

2004; 29:443-52. 

20. Mah TF, O’Toole GA. Mechanisms of biofilm 

resistance to antimicrobial agents. Trends Microbiol 

2001; 9:34-9. 

21. Lewis K. Persister cells and the riddle of biofilm 

survival. Biochemistry (Mosc) 2005; 70:267-74. 

22. Stewart PS, Costerton JW. Antibiotic resistance 

of bacteria in biofilms. Lancet 2001; 358:135-8. 

23. Lewis K. Riddle of biofilm resistance. Antimicrob 

Agents Chemother 2001; 45:999-1007. 

24. Xu KD, McFeters GA, Stewart PS. Biofilm resistance 

to antimicrobial agents. Microbiology 2000; 

146:547-9. 

25. Ehrlich GD, Hu FZ, Shen K, Stoodey P, Post JC. 

Bacterial plurality as a general mechanism driving 

persistance in chronic infections. Clin Orthop 

Relat Res 2005; 437:20-4. 

161

162 


26. Roberts ME, Stewart PS. Modelling protection 

from antimicrobial agents in biofilms through the 

formation of persister cells. Microbiology 2005; 

151:75-80. 

27. Lewis K. Persister cells, dormancy and infectious 

disease. Nat Rev Microbiol 2007; 5:48-56. 

28. Costerton W, Veeh R, Shirtliff M, Pasmore M, 

Post C, Ehrlich G. The application of biofilm science 

to the study and control of chronic bacterial 

infections. J Clin Invest 2003; 112:1466-77. 

29. Costerton JW, Stewart PS, Greenberg EP. Bacterial 

biofilms: a common cause of persistent infections. 

Science 1999; 284:1318-22. 

30. Prakash B, Veeregowda BM, Krishnappa G. Biofilms: 

a survival strategy of bacteria. Curr Sci 

2003; 85:1299-307. 

31. Jensen ET, Kharazmi A, Lam K, Costerton JW, 

Hoiby N. Human polymorphonuclear leukocyte 

response to Pseudomonas aeruginosa grown in 

biofilms. Infect Immun 1990; 58:2383-5. 

32. Leid JG, Shirtliff ME, Costerton JW, Stoodley P. 

Human leukocytes adhere to, penetrate, and respond 

to Staphylococcus aureus biofilms. Infect 

Immun 2002; 70:6339-45. 

33. Cerca N, Jefferson KK, Oliveira R, Pier GB, Azeredo 

J. Comparative antibody-mediated phagocytosis 

of Staphylococcus epidermidis cells 

grown in a biofilm or in the planktonic state. Infect 

Immun 2006; 74:4849-55. 

34. Scheie AA, Petersen FC. The biofilm concept: 

consequences for future prophylaxis of oral diseases? 

Crit Rev Oral Biol Med 2004;15:4-12. 

35. Preshaw PM, Seymour RA, Heasman PA. Current 

concepts in periodontal pathogenesis. Dent 

Update 2004; 31:570-2, 574-8. 

36. Sbordone L, Bortolaia C. Oral microbial biofilms 

and plaque-related diseases:microbial communities 

and their role in the shift from oral health to 

disease. Clin Oral Investig 2003; 7:181-8. 

37. Marsh PD. Dental plaque as a microbial biofilm. 

Caries Res 2004;38:204-11. 

38. Diaz PI, Chalmers NI, Rickard AH i sur. Molecular 

characteriazation of subject-specific oral 

microflora during initial colonization of enamel. 

Appl Environ Microbiol 2006; 72:2837-48. 

39. Palmer RJ Jr, Gordon SM, Cisar JO, Kolenbrander 

PE. Coaggregation-mediated interactions 

of streptococci and actinomyces detected 

in initial human dental plaque. J Bacteriol 2003; 

185:3400-9. 

40. Kolenbrander PE, Ganeshkumar N, Cassels FJ, 

Hughes CV. Coaggregation: specific adherence 

among human oral plaque bacteria. FASEB J 

1993; 7:406-13. 

41. Kolenbrander PE. Oral microbial communities: 

biofilms, interactions, and generic systems. Annu 

Rev Microbiol 2000; 54:413-37. 

42. Kumar PS, Griffen AL, Moeschberger ML, Leys 

EJ. Identification of candidate periodontal pathogens 

and beneficial species by quantitative 16S 

clonal analysis. J Clin Microbiol 2005; 43:3944- 

55. 

43. Pereira MB, Pereira MR, Cantarelli V, Costa 

SS. Prevalence of bacteria in children with otitis 

media with effusion. J Pediatr (Rio J) 2004; 

80:41-8. 

44. Hall-Stoodley L, Hu FZ, Gieseke A, Nistico L, 

Nguyen D, Hayes J, Forbes M, Greenberg DP, 

Dice B, Burrows A, Wackym PA, Stoodly P, Post 

JC, Ehrlich GD, KerschnerJE. Direct detection of 

bacterial biofilms on the middle-ear mucosa of 

children with chronic otitis media. JAMA 2006; 

296:202-11. 

45. Ehrlich GD, Veeh R, Wang X, Costerton JW, 

Hayes JD, Hu FZ, Daigle BJ, Ehrlich MD, Post 

JC. Mucosal biofilm formation on middle-ear 

mucosa in the chinchilla model of otitis media. 

JAMA 2002; 287:1710-5. 

46. Park CW, Han JH, Jeong JH, Cho SH, Kang MJ, 

Tae K, Lee SH. Detection rates of bacteria in 

chronic otitis media with effusion in children. J 

Korean Med Sci 2004; 19:735-8. 

47. Cantekin EI. Bacterial DNA fragments in otitis 

media with effusion. JAMA 1996; 275:186. 

48. Weckx LLM. Presence or absence of bacteria 

in otitis media with effusion? J Pediatr 2004; 

80:5-6. 

49. Post JC, Aul JJ, White GJ, Wadowsky RM, Zavoral 

T, Tabari R, Kerber B, Doyle WJ, Ehrlich 

GD. PCR-based detection of bacterial DNA after 

antimicrobial treatment is indicative of persistent, 

viable bacteria in the chinchilla model of otitis 

media. Am J Otolaryngol 1996; 17:106-11. 

50. Rayner MG, Zhang Y, Gorry MC, Chen Y, Post 

JC, Ehrlich GD. Evidence of bacterial metabolic 

activity in culture-negative otitis media with effusion. 

JAMA 1998; 279:296-9. 

51. Post JC. Direct evidence of bacterial biofilms in 

otitis media. Laryngoscope 2001; 111:2083-94. 

52. Dohar JE, Hebda PA, Veeh R, Awad M, Costerton 

JW, Hayes J, Ehrlich GD. Mucosal biofilm formation 

on middle-ear mucosa in a nonhuman primate 

model of chronic suppurative otitis media. 

Laryngoscope 2005; 115:1469-72. 

53. Hoiby N, Krogh Johansen H, Moser C, Song Z, 

Ciofu O, Kharazmi A. Pseudomonas aeruginosa 

and the in vitro and in vivo biofilm mode of 

growth. Microbes Infect 2001; 3:23-35.

54. Tješić-Drinković D, Tješić-Drinković D, Vraneš 

J, Votava-Raić A, Kelečić J, Gagro A. Imunološki 

aspekt plućne bolesti u cističnoj fibrozi. Paediatr 

Croat 2005; (Supl 1):139-44. 

55. Hoiby N. Pseudomonas in cystic fibrosis: past, 

present, future. 1998. http://www.ecfsoc.org/ 

pa_review/nh_lect.html (Last accessed 16 April 

2007.) 

56. Hentzer M, Teitzel GM, Balzer GJ, Heydorn 

A, Molin S, Givskov M, Parsek MR. Alginate 

overproduction affects Pseudomonas aeruginosa 

biofilm structure and function. J Bacteriol 

2001;183:5395-401. 

57. Singh PK, Schaefer AL, Parsek MR, Moninger 

TO, Welsh MJ, Greenberg EP. Quorum-sensing 

signals indicate that cystic fibrosis lungs are 

infected with bacterial biofilms. Nature 2000; 

407:762-4. 

58. Klausen M, Heydorn A, Ragas P, Lambertsen L, 

Aaes-Jorgensen A, Molin S, Tolker-Nielsen T. 

Biofilm formation by Pseudomonas aeruginosa 

wild type, flagella and type IV pili mutants. Mol 

Microbiol 2003; 48:1511-24. 

59. Haussler S, Ziegle I, Lottel A, von Gotz, Rohde 

M, Wehmhohner D, Saravanamuthu S, Tummler 

B, Steinmetz I. Highly adherent small-colony 

variants of Pseudomonas aeruginosa in cystic 

fibrosis lung infection. J Med Microbiol 2003; 

52:295-301. 

60. Vranes J, Bedenic B, Tjesic-Drinkovic D, Jarza- 

Davila N. In vitro effect of subMICs of antibiotics 

on the antigenic structure of Pseudomonas aeruginosa 

strains isolated from patients with cystic 

fibrosis. Clin Microbiol Infect 2005; 11(Suppl. 

2):394-5. 

61. Hill D, Rose B, Pajkos A, Robinson M, Bye P, 

Bell S, Elkins M, Thompson B, MacLeod C, 

Aaron SD, Harbur C. Antibiotic susceptibilities 

of Pseudomonas aeruginosa isolates derived 

form patients with cystic fibrosis under aerobic, 

anaerobic, and biofilm conditions. J Clin Microbiol 

2005; 43:5085-90. 

62. Frederiksen B, Koch C, Hoiby N. Changing epidemiology 

of Pseudomonas aeruginosa infection 

in Danish cystic fibrosis patients (1974-1995). 

Pediatr Pulmonol 1999; 28:159-66. 

63. Vraneš J. Effect of subminimal inhibitory concentrations 

of azithromycin on adherence of Pseudomonas 

aeruginosa to polystyrene. J Chemother 2000; 

12:280-85. 

64. Hoiby N. New antimicrobials in the menagement 

of cystic fibrosis. J Antimicrob Chemother 2002; 

49:235-8. 

65. Schultz MJ. Macrolide activities beyond their 

antimicrobial effects: macrolides in diffuse panbronchiolitis 

and cystic fibrosis. J Antimicrob 

Chemother 2004; 54:21-8. 


66. Vraneš J, Tješić-Drinković D, Žulj I, Kružić V, 

Turković B, Marić S. In vitro adherence ability 

of Pseudomonas aeruginosa strains isolated from 

patients with cystic fibrosis. Coll Antropol 2004; 

28:675-80. 

67. Gupta K, Stamm WE. Urinary tract infections. 2005. 

http://www.medscape.com/viewarticle/505095 

(6 March 2007.) 

68. Anderson GG, Dodson KW, Hooton TM, Hultgren 

SJ. Intracellular bacterial communities of 

uropathogenic Eschericia coli in urinary tract 

pathogenesis. Trends Microbiol 2004;12:424-30. 

69. Vraneš J, Kružić V, Schoenwald S. Virulence 

characteristics of Escherichia coli strains causing 

asymptomatic bacteriuria. Infection 2003; 

31:216-20. 

70. Anderson GG, Martin SM, Hultgren SJ. Host 

subversion by formation of intracellular bacterial 

communities in the urinary tract. Microbes Infect 

2004; 6:1094-101. 

71. Justice SS, Hung C, Theriot JA, Fletcher DA, 

Anderson GG, Footer MJ, Hultgren SJ. Differentiation 

and developmental pathways of uropathogenic 

Escherichia coli in urinary tract pathogenesis. 

Proc Natl Acad Sci USA 2004; 101:1333-8. 

72. Schembri MA, Klemm P. Biofilm formation in 

a hydrodynamic enviroment by novel fimh variants 

and ramification for virulence. Infect Immun 

2001; 69:1322-8. 

73. Torzewska A, Staczek P, Rozalski A. Crystallization 

of urine mineral components may depend on 

the chemical nature of Proteus endotoxin polysaccharides. 

J Med Microbiol 2003; 52:471-7. 

74. Li X, Zhao H, Lockatell CV, Drachenberg CB, 

Johnson DE, Mobley HL. Visualisation of Proteus 

mirabilis within the matrix of urease-induced 

bladder stones during experimental urinary tract 

infection. Infect Immun 2002;70:389-94. 

75. Nickel JC, McLean RJC. Bacterial biofilms in 

urology. Infect Urol 1998; 11:169-75. 

76. Nickel JC, Emtage J, Costerton JW. Ultrastructural 

microbial ecology of infection-induced urinary 

stones. J Urol 1985; 133:622-7. 

77. Nickel JC, Olson M, McLean RJ, Grant SK, 

Costerton JW. An ecological study of infected urinary 

stone genesis in an animal model. Br J Urol 

1987; 59:21-30. 

78. Cohen TD, Preminger GM. Struvite calculi. Semin 

Nephrol 1996; 16:425-34. 

79. Ahuja SK. Chronic bacterial prostatitis. 

2006. http://www.emedicine.medscape.com/ 

80. 

article/458391-overview (02.05.2009) 

Nickel JC. Chronic prostatitis: an infectious disease? 

Infect Urol 2000; 13:31-8. 

163

164 


81. Ahuja SK. Nonbacterial prostatitis. 2006. http:// 

www.emedicine.medscape.com/article/456165overview 

(Last accessed 2 May 2009.) 

82. Domingue GJ Sr, Hellstrom WJ. Prostatitis. Clin 

Microbiol Rev 1998; 11:604-13. 

83. Krieger JN, Riley DE, Roberts MC, Berger RE. 

Prokaryotic DNA sequences in patients with 

chronic idiopathic prostatitis. J Clin Microbiol 

1996; 34:3120-8. 

84. Nickel JC, Costerton JW. Bacterial localization in 

antibiotic-refractory chronic bacterial prostatitis. 

Prostate 1993; 23:107-14. 

85. Tanner MA, Shoskes D, Shahed A, Pace NR. Prevalence 

of corynebacterial 16S rRNA sequences in 

patients with bacterial and “nonbacterial“ prostatitis. 

J Clin Microbiol 1999; 37:1863-70. 

86. Hochreiter WW, Duncan JL, Schaeffer AJ. Evaluation 

of the bacterial flora of the prostate using a 

16S rRNA gene based polymerase chain reaction. 

J Urol 2000;163:127-30. 

87. Nickel JC, Downey J, Clark J, Ceri H, Olson M. 

Antibiotic pharmacokinetics in the inflamed prostate. 

J Urol 1995; 153:527-9. 

88. Bowler PG, Duerden BI, Armstrong DG. Wound 

microbiology and associated approaches to 

wound management. Clin Microbiol Rev 2001; 

14:244-69. 

89. Vraneš J. Etiopatogeneza i dijagnostika infekcije 

dekubitalnih vrijedova. U: Hančević J, i sur. Dekubitus, 

etiologija, profilaksa i liječenje. Zagreb: 

Medicinska naklada, 2003: 89-105. 

90. Serralta VW, Harrison-Balestra C, Cazzaniga 

AL, Davis SC, Mertz PM. Life styles of bacteria 

in wounds: presence of biofilms? Wounds 

2001;13:29-34. 

91. Percival S, Bowler P. Understanding the effects 

of bacterial communities and biofilms on wound 

healing. 2004. http://www.worldwidewounds. 

com/2004/july/Percival/Community-Interactions-Wounds.html 

(Last accessed 2 May 2009) 

92. Harrison-Balestra C, Cazzaniga AL, Davis SC, 

Mertz PM. A wound-isolated Pseudomonas aeruginosa 

grows a biofilm in vitro within 10 hours 

and is visualized by light microscopy. Dermatol 

Surg 2003; 29:631-5. 

93. Mertz PM. Cuteaneus biofilms:friend or foe? 

Wounds 2003; 15:129-32. 

94. Center for Biofilm Engineering. Module 7, Section 

4: Biofilms in chronic wounds. http://www. 

erc.montana.edu/biofilm-book/MODULE_07/ 

Mod07_S04-2_Blue.htm (Last accessed 2. May 

2009) 

95. Percival SL, Bowler PG. Biofilms and their potencial 

role in wound healing. Wounds 2004; 

16:234-40. 

96. Moore K. Compromised wound healing: a scintific 

approach to treatment. Br J Community Nurs 

2003; 8:274-8. 

97. Singh PK, Parsek MR, Greenberg EP, Welsh MJ. A 

component of innate immunity prevents bacterial 

biofilm development. Nature 2002; 417:552–5. 

98. Rogan MP, Geraghty P, Greene CM, O’Neill SJ, 

Taggart CC, McElvaney NG. Antimicrobial proteins 

and polypeptides in pulmonary innate defence. 

Respir Res 2006; 7: 29. 

99. Cegelski L, Marshall GR, Eldridge GR, Hultgren 

SJ. The biology and future prospects of antivirulence 

therapies. Nat Rev Microbiol 2008; 6:17- 

27. 

100. Johansen C, Falholt P, Gram L. Enzymatic removal 

and disinfection of bacterial biofilms. Appl 

Environ Microbiol 1997; 63:3724-8. 

101. Chaignon P, Sadovskaya I, Ragunah C, Ramasubbu 

N, Kaplan JB, Jabbouri S. Susceptibility of 

staphylococcal biofilms to enzymatic treatments 

depends on their chemical composition. Appl 

Microbiol Biotechnol 2007; 75:125-32.

Significance of microbial biofilm occurence in the pathogenesis 

and treatment of chronic infections 

Jasmina Vraneš 1, 2 , Vladimira Leskovar 2 

1 Zagreb University Medical School, 2 Institute of Public Health ‘’Dr. Andrija Štampar“, Zagreb; Zagreb, Croatia 

ABSTRACT 

The ability of bacterial cells to adhere to biotic and abiotic surfaces, to function as a group and to mutually 

communicate is crucial in the development of chronic infectious diseases. Sessile communities 

of microorganisms today known as biofilm are involved in a number of chronic bacterial infections. 

Key characteristics of biofilm-infections are the persistence of infection and resistance to antimicrobial 

agents and host defenses. Advances in the technology and the application of new microscopic and molecular 

methods while studing ultrastructure and functional relationships inside the biofilm give hope 

that a new therapeutic way to control biofilm-infections, one of the greatest challenges of 21 st century, 

will be found. 

Key words: biofilm, chronic infections, pathogenesis, therapy 

Original submission: 

06 April 2009; 

Revised submission: 

08 April 2009; 

Accepted: 

03 May 2009. 


165

166 

ORIGINAL ARTICLE 

Effect of inoculum size of Enterobacteriaceae producing SHV and 

CTX-M extended-spectrum ß-lactamases on the susceptibility to 

ß-lactam combinations with inhibitors and carbapenems 

Branka Bedenić 1,2 , Jasmina Vraneš 1,3 , Nataša Beader 1,2 , Ines Jajić-Benčić 4 , Vanda Plečko 1,2 , Selma 

Uzunović-Kamberović 5 , Smilja Kalenić 1,2 

1 2 Department of Microbiology, School of Medicine, University of Zagreb; Department of Clinical and Molecular Microbiology, Clinical 

Hospital Center Zagreb; 3Department of Microbiology, Zagreb Institute of Public Health; 4Department of Microbiology, Sisters of Mercy 

Hospital; Zagreb, Croatia; 5Laboratory for Diagnostics, Cantonal Public Health Institution Zenica, Bosnia and Herzegovina 


Branka Bedenić 

Department of Microbiology, School of 

Medicine, University of Zagreb, 

Department of Clinical and Molecular 

Microbiology, Clinical Hospital Center 

Zagreb, 

Kišpatić Street 12, 10 000 Zagreb, Croatia 

Phone: +385 1 23 67 304; 

Fax: +385 1 45 90 130; 

E-mail: branka.bedenic@zg.htnet.hr 


03 June 2008; 


14 August 2008; 

Accepted: 

15 September 2008. 

Med Glas 2009; 6(2): 166-172 

ABSTRACT 

Aim Many extended-spectrum β-lactamases (ESBL) producing 

isolates of E. coli and K. pneumoniae are susceptible in vitro to 

amoxycillin-clavulanate (AMC), ceftazidime-clavulanate (CAZ/ 

cl), and piperacillin-tazobactam (TZP), but MICs increase substantially 

when higher inoculum is applied. The aim of this study 

was to determine the effect of inoculum size on the susceptibility 

of E. coli and K. pneumoniae isolates with well characterized ES- 

BLs, to amoxycillin (AMX), AMC - amoxycilin + clavulanate, 

ceftazidime (CAZ), CAZ/cl - ceftazidime + clavulanate, piperacillin 

(PIP), TZP - tazobactam + piperacilin, imipenem (IMI) and 

meropenem (MEM). 

Methods Minimum inhibitory concentrations (MIC) were determined 

by broth microdilution method using inocula that differed 

100 fold in density. 

Results Inoculum effect for CAZ/cl was detected in 52% of SHV-2 

producing K. pneumoniae strains followed by AMC (43%) and 

TZP (38%). SHV-5 producing K. pneumoniae strains showed the 

most pronounced inoculum effect with CAZ/cl and AMC and to 

lesser extent with TZP. Inoculum effect was observed for AMC, 

CAZ/cl and TZP in 71% of SHV-12 producers. E. coli producing 

SHV-5 β-lactamase showed the most pronounced inoculum 

effect with AMC, followed by CAZ/cl and TZP. Strains producing 

CTX-M β-lactamases had a marked inoculum effect with CAZ/cl, 

AMC and TZP. Carbapenems did not show inoculum effect with 

any type of ESBLs. 

Conclusion According to the results of this study, carbapenems 

remain the antibiotics of choice for the treatment of infections 

caused by ESBL-producing Enterobacteriaceae. 

Key words: inoculum effect, extended spectrum β-lactamases, 

carbapenems, β-lactam/inhibitor combinations

INTRODUCTION 

Extended-spectrum β-lactamases (ESBL) 

are enzymes capable of hydrolyzing oxyiminocephalosporins 

and aztreonam. They are produced 

by a variety of Gram-negative bacilli (1). 

A major problem with ESBLs is their capacity 

to cause therapeutic failures with cephalosporins 

and monobactams even when the causative agent 

appears susceptible in the laboratory tests (2-4). 

In response to this problem CLSI (Clinical and 

Laboratory Standard Institution, former NCCLS) 

recommends that laboratories should report 

ESBL producing isolates of K. pneumoniae and 

E. coli as resistant to penicillins, cephalosporins 

and monobactams regardless of the results of in 

vitro testing (5). There are also questions whether 

β-lactamase inhibitor combinations should 

be used for the therapy of infections caused by 

ESBL pathogens. Many ESBL producing isolates 

of E. coli and K. pneumoniae are susceptible in 

vitro to amoxycillin-clavulanate (AMC), ceftazidime-clavulanate 

(CAZ/cl) and piperacillin-tazobactam 

(TZP), but MICs (minimum inhibitory 

concentration) increases substantially when higher 

inoculum is applied (6-7). Efficacy has been 

reported in animal models but clinical failures 

were reported in patients. Previous studies have 

shown moderate inoculum effect of β-lactamase/ 

inhibitor combinations against Enterobacteriaceae 

in general (6), but there are only few reports so 

far for ESBL positive enteric bacteria with well 

defined resistance mechanisms (7-9) . 

The aim of this study was to determine the 

effect of inoculum size on the susceptibility of E. 

coli and K. pneumoniae isolates with well characterized 

ESBLs to amoxycillin (AMX), amoxycillin/clavulanate 

(AMC), ceftazidime (CAZ), 

ceftazidime/clavulante (CAZ/cl), piperacillin 

(PIP), piperacillin/tazobactam (TZP) and carbapenems 

in comparison with ESBL negative 

strains. Inoculum effect was determined according 

to the type of ESBL in order to determine 

if there are differences in its magnitude between 

different types of ESBLs. 

Bedenić et al Inoculum effect of β-lactam antibiotics 

MATERIAL AND METHODS 

The experiments were performed on the set 

of K. pneumoniae and E. coli isolates with well 

defined resistance mehanisms: 52 K. pneumoniae 

strains producing SHV-5 β-lactamase, 21 K. pneumoniae 

with SHV-2 β-lactamase, seven K. pneumonia 

strains possessing SHV-12 β-lactamase, 

41 E. coli strains producing SHV-5 β-lactamase 

(10-12) and fourteen E. coli strains positive for 

CTX-M β-lactamases (nine CTX-M-3 and five- 

CTX-M-15) (Bedenić B, unpublished data). 

Twenty six ESBL negative isolates of K. pneumoniae 

were used as the control group. The 

β-lactamases were characterized by isoelectric 

focusing, PCR and sequencing of bla ESBL genes. 

Minimum inhibitory concentrations (MIC) of 

amoxycillin (AMX), amoxycillin/clavulanate 

(AMC), ceftazidime (CAZ), ceftazidime/clavulanic 

acid (CAZ/cl), piperacillin (PIP), piperacillin/tazobactam 

(TZP), imipenem (IMI) and 

meropenem (MEM) were determined by broth 

microdilution method using inocula that differed 

100 fold in density according to CLSI (5). The 

inocula contained 10 5 CFU/ml and 10 7 CFU/ 

ml approximately in Mueller-Hinton broth. The 

MIC (minimum inhibitory concentration) was 

defined as the lowest antibiotic concentration 

that prevented the visible growth of bacteria after 

incubation at 37°C for 18 h. Inoculum effect was 

defined as at least eightfold increase in antibiotic 

MIC in the presence of high inoculum compared 

to standard inoculum size (7). 

RESULTS 

Inoculum effect for CAZ/cl was detected in 

52% of SHV-2 producing K. pneumoniae strains 

followed by AMC (43%) and TZP (38%). Two 

strains showed inoculum effect with imipenem. 

SHV-5 producing K. pneumoniae strains showed 

the most pronounced inoculum effect with CAZ/ 

cl (57%) and AMC (55%) and to lesser extent 

with TZP (44%). Two strains showed inoculum 

effect with meropenem (Table 1). 

167

168 


Table 1. Percentage of strains showing inoculum effect with ß-lactam/inhibitor combinations and carbapenems, according to the 

type of ESBL. 

Type of β-lactamase 

K. pneumoniae 

AMC CAZ/cl 

Antibiotic* 

TZP IMI MEM 

ESBL-negative 1/26 (3.8%) 0/26 (0%) 1/26 (3.8%) 0/26 (0%) 0/26 (0%) 

SHV-2 9/21 (43%) 11/21 (52%) 8/21 (38%) 2/21 (9.5%) 0/21 (0%) 

SHV-5 29/52 (55%) 30/52 (57%) 23/52 (44%) 0/52 (0 %) 2/52 (3.8 %) 

SHV-12 

E. coli 

5/7 (71%) 5/7 (71%) 5/7 (71%) 0/7 (0%) 0/7 (0%) 

SHV-5 25/41 (61%) 21/41 (51%) 9/41 (22%) 0/41 (0%) 0/41 (0%) 

CTX-M 8/14 (57%) 10/14 (71%) 7/14 (50) 0/14 (0%) 1/14 (7.1%) 

*AMC, amoxycillin/clavulanate, CAZ/cl, ceftazidime/clavulanate; TZP, piperacillin/tazobactam; IMI, imipenem; MEM, meropenem; 

Inoculum effect was observed for AMC, 

CAZ/cl and TZP in 71% of SHV-12 producers. 

None of the strains showed inoculum effect for 

the carbapenems (Table 1). 

E. coli producing SHV-5 β-lactamase showed 

the most pronounced inoculum effect with AMC 

(61%) followed by CAZ/cl (51%) (Table 1). TZP 

had the least inoculum effect (22%). Carbapenems 

were not affected. 

Strains producing CTX-M β-lactamases had 

a marked inoculum effect with CAZ/cl (71%), 

AMC (57%) and TZP (50%). One strain exhibited 

inoculum effect with meropenem (Table 1). 

The concentration necessary to inhibit 90% 

of the SHV-2 producing K. pneumoniae rose 

from 128 to ≥1024 mg/l for AMC and TZP, from 

256 to ≥1024 mg/L for CAZ, and from 4 to 32 

for CAZ/cl when high inoculum was applied as 

Table 2. MIC range, cumulative MIC values and percentage of resistant strains at standard and high inoculum testing, for Klebsiella 

pneumoniae strains producing SHV-ESBLs 

Standard inoculum High inoculum 

Antibiotic MIC range MIC 50 MIC 90 %R MIC range MIC 50 MIC 90 %R 

K. pneumoniae SHV-2 (n=21) 

amoxycillin ≥1024-≥1024 ≥1024 ≥1024 100 ≥1024-≥1024 ≥1024 ≥1024 100 

amoxycillin/clavulanate 1->1024 16 128 42.8 8->1024 128 ≥1024 90.5 

ceftazidime 4-512 32 256 76.2 16->1024 128 ≥1024 95.2 

ceftazidime/clavulanate 0.25-4 1 4 0 0.5-64 8 32 9.5 

piperacillin ≥1024-≥1024 ≥1024 ≥1024 100 ≥1024-≥1024 ≥1024 ≥1024 100 

piperacillin/tazobactam 4-256 32 128 19 32-≥1024 128 ≥1024 57 

imipenem ≤0.016-1 0.12 1 0 0.06-4 0.25 4 0 

meropenem ≤0.016-0.25 0.06 0.25 0 0.03-1 0.12 0.5 0 


amoxycillin ≥1024-≥1024 ≥1024 ≥1024 100 ≥1024-≥1024 ≥1024 ≥1024 100 

amoxycillin/clavulanate 1-≥1024 64 128 80.7 8->1024 128 ≥1024 98 

ceftazidime 1-≥1024 ≥1024 ≥1024 98 128->1024 ≥1024 ≥1024 100 

ceftazidime/clavulanate 0.12-16 0.25 4 0 0.25-64 8 32 38.4 

piperacillin ≥1024-≥1024 ≥1024 ≥1024 100 ≥1024-≥1024 ≥1024 ≥1024 100 

piperacillin/tazobactam 16-256 16 256 38.4 32-≥1024 128 ≥1024 75 

imipenem 0.06-1 0.25 0.5 0 0.06-4 0.25 1 0 

meropenem 0.016-2 0.03 025 0.25 0.03-2 0.12 0.5 0 


amoxycillin ≥1024-≥1024 ≥1024 ≥1024 100 ≥1024-≥1024 ≥1024 ≥1024 100 

amoxycillin/clavulanate 32->1024 128 ≥1024 100 256-≥1024 512 ≥1024 100 

ceftazidime 64-≥1024 128 ≥1024 100 256-≥1024 512 ≥1024 100 

ceftazidime/clavulanate 0.25-4 1 4 0 1-32 8 32 14.1 

piperacillin ≥1024-≥1024 ≥1024 ≥1024 100 ≥1024-≥1024 ≥1024 ≥1024 100 

piperacillin/tazobactam 32-128 128 128 57.1 128-≥1024 128 ≥1024 100 

imipenem 0.25-1 0.5 1 0 0.25-4 1 2 0 

meropenem 0.06-0.25 0.12 0.25 0 0.12-2 0.12 1 0

compared to the standard. Meropenem and imipenem 

were not affected by inoculum size with 

MIC 90 values of 0.25 and 1 mg/L respectively 

when standard inoculum was applied and MIC 90 

of 0.5 and 4 mg/L in high inoculum testing respectively. 

With increased inoculum the percentage 

of SHV-2 producers resistant to AMC rose 

from 43 to 90%, to CAZ from 76% to 95% and to 

TZP from 19% to 57%. At the standard inoculum 

testing none of the SHV-2 producers were resistant 

to CAZ/cl whereas at high inoculum 9.5% of 

the strains became resistant (Table 2). 

With SHV-5 producing K. pneumoniae the 

highest increase in MIC 90 due to inoculum effect 

was observed for CAZ/cl (4 to 32 mg/L) and AMC 

(128 to >1024 mg/L) followed by TZP (256 to 

≥1024 mg/L) whereas carbapenems showed only 

slight increase of the concentration necessary to 

inhibit 90% of the strains (0.5 to 1 mg/L for imipenem 

and 0.25 to 0.5 mg/L for meropenem). At 

the standard inoculum testing none of the SHV-5 

producers was resistant to CAZ/cl while at high 

inoculum 38% of the strains showed resistance 

(Table 2). The percentage of resistant strains was 

also significantly increased due to inoculum effect 

for TZP (38% to 75%) and AMC (81 to 98%). 

MIC 90 for SHV-12 producers at standard inoculum 

size was ≥1024 for AMX, for TZP 128 

mg/L, for CAZ/cl 4 mg/l, for IMI 1 mg/L and for 

MEM 0.25 mg/L whereas at high inoculum size it 

reached ≥1024 mg/l for AMX, AMC, CAZ, PIP 

and TZP, 32 mg/l for CAZ/cl, 2 mg/L for IMI and 


Table 3. MIC range, cumulative MIC values and percentage of resistant strains at standard and high inoculum testing, for 

Escherihia coli strains producing SHV and CTX-M-ESBLs. 


Antibiotic MIC range MIC50 MIC90 %R MIC range 

E. coli - SHV-5 (n=41) 

MIC50 MIC90 %R 

amoxycillin 512≥1024 ≥1024 ≥1024 100 512≥1024 ≥1024 ≥1024 100 

amoxycillin/clavulanate 4-64 8 32 14.6 16-128 >128 128 90 

ceftazidime 16≥1024 256 ≥1024 95.1 32->1024 ≥1024 ≥1024 100 

ceftazidime/clavulanate 0.06-8 0.5 4 0 0.06-64 4 32 7.3 

piperacillin 512≥1024 ≥1024 ≥1024 100 512≥1024 ≥1024 ≥1024 100 

piperacillin/tazobactam 8-128 32 128 9.7 32-512 128 512 53.6 

imipenem 0.06-0.25 0.12 0.5 0 0.06-2 0.25 2 0 

meropenem 0.016 0.03 0.03 0 0.016-0.12 0.03 0.12 0 

E. coli - CTX-M (n=14) 

amoxycillin 64-≥1024 ≥1024 ≥1024 100 ≥1024-≥1024 ≥1024 ≥1024 100 

amoxycillin/clavulanate 1-64 16 64 42.8 8-512 128 512 92.8 

ceftazidime 0.25-32 4 32 35.1 2-512 32 512 57.1 

ceftazidime/clavulanate 0.06-2 0.5 1 0 1-16 4 8 0 

piperacillin 64-≥1024 ≥1024 ≥1024 100 ≥1024-≥1024 ≥1024 ≥1024 100 

piperacillin/tazobactam 2-128 15 128 42.8 16-≥1024 256 ≥1024 64.2 

imipenem 0.06-1 0.25 1 0 0.12-4 0.5 4 0 

meropenem 0.03-0.25 0.12 0.25 0 0.06-2 0.25 1 0 

1 mg/L for MEM. At the standard inoculum testing 

all strains were resistant to AMX, AMC, PIP 

and CAZ, whereas 57% were resistant to TZP. 

No resistance to CAZ/cl, IMI and MEM was observed. 

At high inoculum percentage of strains 

resistant to TZP rose to 100 % and to CAZ/cl to 

14.1% but the susceptibility IMI and MEM was 

maintained in spite of slightly higher MIC values 

for particular strains (Table 2). 

The concentration necessary to inhibit 90% 

of the SHV-5 producing E. coli strains rose for 

two dilutions with increased inoculum for AMC 

(32 →128 mg/L), TZP (128→512 mg/L), imipenem 

(0.5→2 mg/L) and meropenem (0.03→0.12 

mg/L) and for three dilutions in case of CAZ/cl 

(4→32 mg/L). When the inoculum was increased 

100 fold, resistance increased from 14 to 90% 

for AMC, from 10 to 53% for TZP and from 0 to 

7% for CAZ/cl (Table 3). 

The significant increase in the concentration 

that inhibited 90% of the CTX-M producers due 

to inoculum effect was obtained with AMC (64 

→512 mg/L), CAZ/cl (1→8 mg/L) TZP (128 

→≥1024 mg/L), where MICs of carbapenems did 

not have a marked increase in MIC 90 at high inoculum 

testing (two dilutions). When the inoculum 

was increased 100 fold resistance of CTX-M 

positive E. coli strains was increased from 43 to 

93% for AMC, from 35 to 57% for CAZ and from 

43 to 64% for TZP. All CTX-M producers maintained 

susceptibility to CAZ/cl and carbapenems 

even with high inoculum testing (Table 3). 

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170 


ESBL negative strains did not display in- 

oculum effect with any antibiotic tested. MIC 90 

of AMX, AMC, CAZ, CAZ/cl, PIP, TZP, IMI, 

and MEM was 8, 2, 0.5, 0.25, 8, 4, 0.12 and 0.06 

mg/L respectively in the presence of the standard 

inoculum while the values in the presence of high 

inoculum were 32, 8, 2, 1, 16, 8, 0.5 and 0.12 

mg/L respectively (Table 4). All ESBL negative 

strains were susceptible to all tested antibiotics at 

the standard inoculum testing. When testing was 

performed with high inoculum 19% of the ESBL 

negative strains were resistant to AMX, but no 

resistance to any other antibiotic was observed 

(Table 4). 

AMC and CAZ/cl were associated with inoculum 

effect against all type of ESBL producers: 

SHV-2, SHV-5, SHV-12 and CTX-M. TZP was 

less affected by the inoculum size then AMC, 

and CAZ/cl particularly with CTX-M producers. 

It was not possible to determine inoculum 

effect for AMX, PIP and CAZ alone because of 

the predominantly off- scale MIC values which 

exceeded 1024 mg/l even when tested with the 

standard inoculum size. 

DISCUSSION 

Clinicians rely on the results of in vitro 

susceptibility testing to choose appropriate antimicrobial 

agent for the therapy. Results of in 

vitro testing depend on many factors including 

inoculum effect (6). Inoculum effect was previously 

described for ceftazidime, cefotaxime, 

cefepime and other cephalosporins (13-15), but 

there are only few reports of inoculum effect 

with β-lactam/inhibitor combinations (6). Previous 

studies have shown small inoculum effect of 

β-lactamase/inhibitor combinations on Enterobacteriaceae 

in general (6), but in this research we 

studied the inoculum effect of these compounds 

in enteric bacteria with well defined resistance 

mechanisms. The studies on animal models have 

shown failures of ceftriaxone/sulbactam combination 

in experimental rabbit endocarditis due 

to the high density of K. pneumoniae producing 

TEM-3 β-lactamase (8) and E. coli producing 

SHV-2 β-lactamase in the cardiac vegetations (9). 

According to the results of this study, inoculum 

effect for all tested compounds was more pronounced 

for ESBL positive strains in comparison 

with ESBL negative. This is in concordance with 

previous reports which found the inoculum effect 

to be more significant if the antibiotic is susceptible 

to hydrolysis by a certain β-lactamase (7,13- 

14). It can lead to therapeutic failures if infections 

caused by ESBL producing microorganisms are 

treated with expanded-spectrum cephalosporins. 

Inoculum effect occurs when a bacterium produces 

enzyme capable of hydrolyzing an antibiotic 

(7). There are two explanations for the inoculum 

effect: antibiotic destruction by β-lactamases 

and filamentous transformations with continued 

growth (6). Susceptibility to AMC and CAZ/cl 

was more affected by inoculum size than TZP. 

There were slight differences observed in the 

magnitude of the inoculum effect with different 

types of ESBLs. The activity of TZP was mostly 

compromised in the presence of high density of 

SHV-5 producing K. pneumoniae. The fact that 

SHV-5 and SHV-12 producers showed the higher 

increase in the percentage of resistant strains for 

CAZ/cl in comparison with SHV-2 and CTX-M 

producers due to inoculum effect could be explained 

with higher hydrolysis rate of ceftazidime 

by SHV-5 and SHV-12 β-lactamase. Car- 

Table 4. MIC range, cumulative MIC values and percentage of resistant strains at standard and high inoculum testing, for ESBL 

negative Klebsiella pneumoniae strains. 

ESBL negative K. pneumoniae (n=26) 


Antibiotic 

amoxycillin 

MIC range 

0.5-16 

MIC50 2 

MIC90 8 

%R 

0 

MIC range 

0.5-64 

MIC50 4 

MIC90 32 

%R 

19.2 

amoxycillin/clavulanate 0.5-4 2 2 0 1-16 2 8 0 

ceftazidime 0.03-0.5 0.12 0.5 0 0.06-4 0.25 2 0 

ceftazidime/clavulanate 0.03-0.5 0.12 0.25 0 0.06-1 0.25 1 0 

piperacillin 0.5-8 4 8 0 1-32 4 16 0 

piperacillin/tazobactam 0.5-4 2 4 0 1-16 2 8 0 

imipenem

apenems were the most stable to inoculum efect 

regardless of the type of ESBL. This observation 

is in concordance with previous reports (16-17). 

For that reason carbapenems which are stable in 

the presence of high inoculum should be antibiotics 

of choice for the treatment of infections 

caused by ESBL producing Enterobacteriaceae. 

β-lactamase/inhibitor combinations should be 

avoided in the therapy because of the inoculum 

effect and development of hyperproducing variants 

during treatment which are not sufficiently 

inhibited with therapeutic concentrations of clavulanic 

acid or sulbactam (18). AMC could be 

used for the treatment of urinary tract infections 

caused by ESBL producing Enterobacteriaceae 

due to its high concentrations in urine which 

REFERENCES 

1. Bradford PA. Extended-spectrum β-lactamases in 

the 21st century: characterization, epidemiology, 

and detection of this important resistance threat. 

Clin Microbiol Rev 2001; 14:933-51. 

2. Paterson DL. Recommendation for treatment of 

severe infections caused by Enterobacteriaceae 

producing extended-spectrum β-lactamases (ES- 

BLs). Clin Microbiol Infect 2000; 6:460-3. 

3. Paterson DL, Ko WC, von Gottberg A, Casellas 

JM, Mulazimoglu L, Klugman KP, Bonomo 

RA, Rice L, McCormack J, Yu V. Outcome of 

cephalosporin treatment for serious infections 

due to apparently susceptible organisms producing 

extended-spectrum β-lactamases: implication 

for the clinical microbiology laboratory. J Clin 

Microbiol 2001; 39:2206-12. 

4. Karas JA, Pillay DG, Muckart D, Sturm W. 

Treatment failure due to extended-spectrum 

β-lactamase. J Antimicrob Chemother 1996; 

37:203-4. 

5. CLSI. Performance Standards for Antimicrobial 

Susceptibility Testing. Methods for dilution antimicrobial 

susceptibility tests for bacteria that 

grow aerobically. Eighteen Informational Supplement. 

CLSI document M100-S18. Wayne, 

PA: Clinical and Laboratory Standards Institute; 

2008. 


overwhelm the inoculum effect and prevent development 

of hyperproducing mutants. Combinations 

of expanded-spectrum cephalosporins 

with β-lactamase inhibitors are not available at 

Croatian market but combination of cefoperazone 

with sulbactam is registered in France (18). 

The other important drawback of β-lactamase/inhibitor 

combinations is the selection of inhibitor 

resistant β-lactamases (18). 

ACKNOWLEDGEMENT/DISCLOSURE 

This research was supported by Croatian 

Ministry of Science, Education and Sport (Grant 

No 108-1080114-0015). 

6. 

7. 

8. 

9. 

Competing interests: none decleared. 

Goldstein EJ, Citron DM, Cherubin CE. Comparison 

of the inoculum effects of members of the 

family Enterobacteriaceae on cefoxitin and other 

cephalosporins, β-lactamase inhibitor combinations, 

and the penicillin-derived component of 

these combinations. Antimicrob Agents Chemother 

1991; 35:560-6. 

Thomson KS, Smith-Molland E. Cefepime, 

piperacillin:tazobactam, and the inoculum effect 

in tests with extended-spectrum β-lactamase producing 

Enterobacteriaceae. Antimicrob Agents 

Chemother 2001; 45: 3548-54. 

Caron F, Gutmann L, Bure A, Pangon B, Vallois 

JM, Pechinot A, Carbon C. Ceftriaxonesulbactam 

combinations in rabbit endocarditis 

caused by a strain of Klebsiella pneumoniae producing 

extended-spectrum TEM-3 β-lactamase. 

Antimicrob Agents Chemother 1990; 34: 2070-4. 

Fantin B, Pangon B, Potel G, Caron F, Vallee E, 

Vallois JM, Mohler J, Bure A, Philippon A, Carbon 

C. Activity of sulbactam in combinations with 

ceftriaxone in vitro and in experimental endocarditis 

caused by Escherichia coli producing SHV-2 

likw β-lactamase. Antimicrob Agents Chemother 

1990; 14. 581-6. 

171

172 


10. Bedenić B, Žagar Ž. Extended-spectrum 

11. 

β-lactamases in clinical isolates of Klebsiella 

pneumoniae from Zagreb, Croatia. J Chemother 

1998;10:449-59. 

Bedenić B, Randegger CC, Stobberingh E, 

Hachler H. Molecular epidemiology of extendedspectrum 

β-lactamases from Klebsiella pneumoniae 

strains isolated in Zagreb, Croatia. Eur J Clin 

Microbiol Infect Dis 2001; 20:505-8. 

12. Bedenić B, Schmidt H, Herold S, Monaco M, 

Plečko V, Kalenić S, Skrlin J. Spread of Klebsiella 

pneumoniae producing SHV-5 β-lactamase 

in Dubrava University Hospital, Zagreb. J Chemother 

2005; 17:367-75. 

13. Queenan AM; Foleno B, Gownley C, Wira E, 

Bush K. Effects of inoculum and β-lactamase 

activity in AmpC and extended-spectrum 

β-lactamase (ESBL)-producing Escherichia coli 

and Klebsiella pneumoniae clinical isolates tested 

by using NCCLS ESBL methodology. J Clin 

Microbiol 2004; 42:269-75. 

14. Kang CI, Pai, H, Kim SB, Kim HB, Kim EC, Oh 

MD, Choe KW. Cefepime and the inoculum effect 

in tests with Klebsiella pneumoniae producing 

plasmid-mediated AmpC-type β-lactamase. J 

Antimicrob Chemother 2004; 54:1130-3. 

15. Bedenić B, Beader N, Žagar Ž. Effect of inoculum 

size on the antibacterial activity of cefpirome and 

cefepime against Klebsiella pneumoniae strains 

producing SHV extended-spectrum β-lactamases. 

Clin Microbiol Infect 2001; 7: 626-35. 

16. Wiseman LR, Wagstaff AJ, Brogden RN, Bryson 

HM: Meropenem: A Review of its antibacterial 

activity, pharmacokinetic properties and clinical 

efficacy. Drugs 1995; 50:73-101. 

17. Betriu C, Salso S, Sanchez A, Culebras E, 

Gomez M, Rodrigez-Avial I, Picazo JJ. Comparative 

in vitro activity and the inoculum effect of 

ertapenem against Enterobacteriaceae resistant to 

extended-spectrum cephalosporins. Int J Antimicrob 

Agents 2006; 28:1-5. 

18. Amyes SGB, Miles RS. Extended-spectrum 

β-lactamases: the role of inhibitors in the therapy 

1998; 42:415-7.


Comparison of the frequency and the occurrence of antimicrobial 

resistance among C. jejuni and C. coli isolated from human infections, 

retail poultry meat and poultry in Zenica-Doboj Canton, 


Selma Uzunović-Kamberović 1 , Tina Zorman 2 , Ingrid Berce 3 , Lieve Herman 4 , Sonja Smole Možina 2 

1 2 Cantonal Public Health Institute Zenica, Laboratory for Clinical and Sanitary Microbiology, Zenica, Bosnia and Herzegovina; University 

of Ljubljana, Biotechnical Faculty, Department for Food science and Technology, Ljubljana, Slovenia; 3Institute of Public Health 

Nova Gorica, Nova Gorica, Slovenia; 4Agricultural Research Center-Ghent, Department for Animal Product Quality and Transformation 

Technology, Melle, Belgium; 


Selma Uzunović-Kamberović, 

Cantonal Public Health Institute Zenica, 

Laboratory for Clinical and Sanitary 

Microbiology, 


Phone: +387 32 443 580; 

Fax.: +387 32 443 530; 

Email: selma_kamb@yahoo.com 


06 January 2009; 


17 March 2009; 

Accepted: 

06 April 2009. 

Med Glas 2009; 6(2): 173-180 

ABSTRACT 

Aim To compare the frequency of isolation and occurrence of antimicrobial 

resistance among C. jejuni and C. coli isolated in humans, 

retail poultry meat and poultry. 

Methods Fifty-three human, 52 retail poultry meat and 15 poultry 

Campylobacter jejuni/coli isolates were investigated for antibiotic 

susceptibility to eight antimicrobials by disk-diffusion method. 

Erythromycin and ciprofloxacin susceptibility were further determined 

by E-test, and additionally the MICs of erythromycin 

and ciprofloxacin were determined using the broth microdilution 

method. 

Results Prevalence of C. coli in humans, retail poultry meat and 

poultry was 28.3%, 56.9% and 53.3%, respectively. No significant 

differences were found in the overall resistance rates between C. 

jejuni and C. coli isolated from all three sources (p>0.05). Erythromycin 

and ciprofloxacin resistance was high and similar in humans, 

retail poultry meat and poultry (26.4%, 35.3%, 26.7%, and 

32.1%, 23.5%, 26.7%, respectively) (p>0.05). C. jejuni displayed 

higher prevalence of resistance to erythromycin than C. coli in 

all investigated sources (p>0.05). All ciprofloxacin and 94.4% of 

erythromycin positive isolates were highly resistant (≥ 32 μg/mL 

and ≥128 μg/mL, respectively). 

Conclusion The high prevalence of C. coli isolates from humans, 

poultry meat and poultry and higher both overall and erythromycin-resistance 

in C. jejuni than in C. coli isolates suggests that there 

may be a common source in the environment, which might be absent 

in other geographical regions. Further studies are required 

to determine the role of efflux mechanism in erythromycin- and 

ciprofloxacin-resistance related to the level of resistance. 

Key words: ciprofloxacin-resistance, erythromycin-resistance, 

Bosnia and Herzegovina, Campylobacter jejuni, Campylobacter 

coli 

173

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INTRODUCTION 

Campylobacter species are one of the most 

common inducers of bacterial diarrhoea in humans 

worldwide (1). Campylobacters is considered 

a zoonotic disease, and occur in the intestine 

of domestic, production and wild animals. Transmission 

to humans occurs via food, drinking water 

and pets (2,3). The major route of infection 

in humans is thought to be the consumption of 

contaminated poultry meat, probably because of 

the high prevalence of contamination of chicken 

carcasses with Campylobacter and the frequency 

of poultry consumption (2, 4-7). Although most 

reports based on molecular typing have shown a 

major contribution of poultry to human Campylobacter 

infections, its epidemiology is still not 

completely defined (8,9). 

Erythromycin and fluoroquinolones are considered 

the drugs of choice for the treatment of 

gastrointestinal infections. An increase of antibiotic 

resistance of human Campylobacter isolates, 

especially to fluoroquinolones has been reported 

in many countries, but resistance to erythromycin 

and other antimicrobials has also been observed 

(10-12). As Campylobacter may be transferred 

from animals to humans, the possible development 

of antimicrobial resistance in Campylobacter 

spp., due to the use of antimicrobial agents in food 

animals, is a matter of concern (10,13). 

C. jejuni isolated from clinical infections is 

generally susceptible to erythromycin, whereas 

a much higher level of erythromycin resistance 

among C. coli isolates has been reported (10,14). 

Until recently, the fact that the majority of C. 

coli isolates were usually obtained from pigs, 

suggested that they were the most probable food 

source of human infections with C. coli (14). 

Since 1991 in Zenica-Doboj Canton, Bosnia 

and Herzegovina region, a significant proportion 

of C. coli in human infections has been 

reported as compared to other countries in both 

asymptomatic carriers and diarrhoeic patients 

comprising 36% and 26.5% of thermo tolerant 

Camyplobacter isolates (15,16). Moreover, C. 

coli isolates showed no difference to erythromy- 

cin-resistance as compared to C. jejuni isolates in 

this region (11). 

The majority of C. coli isolates analyzed in 

previous studies was obtained from pigs, suggesting 

that pigs were the most probable source of human 

infections with C. coli, rather than chicken 

and cattle (17). If pigs were the source of human 

C. coli infections, it would be surprising given 

that the ethnic structure of the Zenica-Doboj Canton 

population has changed due to mass migration 

during the wartime, with Muslims accounting 

for 82.3% of the post-war population (Statistical 

yearbook of R/F B&H, Sarajevo, 2000, 2004). 

For Muslims the consumption of pork is almost 

nonexistent and for that reason in the Zenica city 

there was no pork available in the markets before 

2004. This suggested that the primary source of 

C. coli infections might be other than pigs. 

The aim of this study was the comparison of 

antimicrobial resistance among C. jejuni and C. 

coli isolated from human infections, retail poultry 

meat and poultry in Zenica-Doboj Canton, 

Bosnia and Herzegovina. 

MATERIALS AND METHODS 

The Laboratory for Sanitary and Clinical 

Microbiology of the Cantonal Public Health Institute 

in Zenica serves a total population of 331,229 

inhabitants in Zenica-Doboj Canton: 149,053 in 

the urban area and 182,176 in the rural area. During 

the entire year of 2002, stool specimens were 

received from 2,491 consecutive outpatients with 

sporadic diarrhoea. There were 1,557 specimens 

taken from children (0-6 years of age), 331 from 

elementary school students (7-14 years of age), 

204 from high school students (15-19 years of 

age), 311 and 88 from adults (20-64 and >64 

years of age, respectively). The samples were 

cultured on modified Preston medium (OXOID, 

Basingstoke, United Kingdom) and incubated in 

a microaerophilic atmosphere (CampyGen, OX- 

OID) at 42 °C for 48 h. 

A total of 147 samples of retail poultry meat 

products (25 samples of chicken liver and 122

samples of poultry leg skin) from 53 different 

markets in the central zone of the Zenica city 

were examined for the presence of C. jejuni and 

C. coli during thirteen sampling visits between 

May and October 2002. Sampling was done by 

laboratory technicians with a permission of market 

managers. All poultry samples found in the 

markets which originated from different countries 

were sampled. Poultry meat samples came 

from 14 national (81 samples) and 7 international 

chicken meat producers (66 samples) imported 

from Croatia and Germany (20 samples from 

each country), Slovenia (22 samples), Turkey 

and Holland (2 samples from each country). For 

the isolation of Campylobacter from poultry 

meat, the standardized procedure recommended 

by ISO 10272 was followed (9,18). Chicken liver 

or skin from legs (5 g) were enriched in 45 mL of 

selective Preston broth (Oxoid), containing 5% 

of horse blood (SR 048C, Oxoid) and incubated 

in a microaerophilic atmosphere for 18 hours at 

42 °C (CampyGen, Oxoid). One loopful of enrichment 

broth was streaked on modified Preston 

medium (Oxoid) and incubated in a microaerophilic 

atmosphere at 42°C for 3 days. 

We also isolated 15 C. jejuni C. coli strains 

from 23 cloacal samples of chicken collected 

from the biggest local farm with conventional 

housing, and production of 750 kg/month. Sampling 

was done by farm staff with farm owner’s 

permission. A questionnaire about the contents of 

food and antibiotics given to poultry (duration of 

breeding before slaughtering, indication for antibiotic 

distribution), monthly production, a place 

of one-day storage of chickens was filled by a 

farm owner. The single sampling took place in 

July 2001. Isolates were stored at -70°C in a medium 

consisting of nutrient broth No. 2 (CM0271 

Oxoid) (32 g), agar (1.2 g), glycerol (150 mL) 

and distilled water (up to 1000 mL), supplemented 

with two vials of Campylobacter growth supplement 

(SR0232E, Oxoid, Basingstoke, United 

Kingdom). 

After original isolation, the isolates were 

long-term stored at -80°C in Biotechnical Faculty 

in Ljubljana (Slovenia) for further studies. 

Uzunović-Kamberović et al Antimicrobial resistance C. jejuni and C. coli 

C. jejuni and C. coli were identified using 

standard microbiological methods and multiplex 

PCR (5,19). 

The disc diffusion method was performed to 

test the resistance to eight antimicrobials used in 

human and veterinary medicine (Oxoid): ampicillin 

(10 µg); erythromycin (15 µg); gentamicin 

(10 µg), tetracycline (30 µg), chloramphenicol 

(30 µg) nalidixic acid (30 µg), ciprofloxacin (5 

µg); nitrofurantoin (300 µg). The inocula were 

adjusted to turbidity of a 0.5 McFarland standard 

and plated on Mueller-Hinton agar (Oxoid, 

Basingstoke, UK) supplemented with 5% sheep 

blood. The plates were incubated at 37°C for 48 

hrs in a microaerobic atmosphere. The applied 

susceptibility criteria were in accordance with 

CLSI (NCCLS) [20]. The following cutoff values 

were used: ampicillin, ≤ 13 mm, erythromycin, ≤ 

13 mm, gentamicin, ≤ 12 mm, tetracycline, ≤ 14 

mm, chloramphenicol, ≤ 12 mm, nalidixic acid, 

≤ 13 mm, ciprofloxacin, ≤ 15 mm, nitrofurantoin, 

≤ 14 mm. 

C. jejuni ATCC 3356, E. coli ATCC 25922 

and Staphylococcus aureus ATCC 25923 control 

strains were used. 

Erythromycin and ciprofloxacin susceptibility 

were further determined by Etest (AB Biodisc, 

Solna, Sweden) as described previously (21). 

The MICs (minimal inhibitory concentration) 

of erythromycin and ciprofloxacin (Sigma 

Aldrich, Saint Louis, USA) in Campylobacter 

isolates were determined using the broth microdilution 

method as described previously (20). For 

erythromycin the method was slightly modified: 

two-fold serial dilutions of erythromycin were 

used at the concentrations from 0.015 to 512 μg/ 

mL. The MICs lowest concentration where no 

growth was observed was determined on the base 

of fluorescent signal measured by Microplate 

Reader (Tecan, Mannedorf/Zurich, Switzerland) 

after adding CellTiter-Blue Reagent ® following 

manufacturer’s instructions (Promega Corporation, 

Madison, USA) to culture the media. Isolates 

were considered resistant to erythromycin 

when MIC ≥ 32 mg/L, and resistant to cipro- 

175

176 


floxacin when MIC ≥ 4 mg/L. The strains that 

repeatedly presented the MIC of erythromycin 

and ciprofloxacin of

etween them (p>0.05). The resistance rates to 

erythromycin and ciprofloxacin of clinical isolates 

were higher in C. jejuni, 29.7% and 35.1%, 

respectively, than in C. coli, 20.0% and 26.7%, 

respectively (p>0.05). It is true for retail poultry 

and poultry isolates too. All ciprofloxacin positive 

isolates had a high-level resistance (≥ 32 μg/mL), 

and 94.4 % of erythromycin positive isolates had 

high-level resistance (≥128 μg/mL) (Table 2). 

Significantly higher prevalence of resistance 

for both erythromycin and ciprofloxacin was observed 

in the isolates from the age group of 20-64 

(53.8% for both antibiotics) as compared to the 

age group of 0-6 (23.3% for ciprofloxacin and 

22.3% for erythromycin) (data not shown). 

DISCUSSION 

Resistance rates to one or more antibiotics 

as found in this study for Campylobacter strains 

have surpassed the highest previously reported 

resistance rates for human and poultry meat isolates 

(4,23,24). Reportedly, multidrug resistant 

(MDR) isolates are usually present in humans to 

a much lesser extent (0.8% to 21%) compared to 

the results from this study (23-25). 

A significant increase in ciprofloxacin resistance 

of human isolates in this region between 

1998 (14%) and 2002 (32.1%) was observed 

(1). Several studies have shown that food animals 

can be a substantial source of human infections 

and that the same serotypes and genotypes 

can be isolated from humans and food animals 

(10,14). The consumption of imported chickens 

was identified as a possible risk factor for the 

acquisition of fluoroquinolone-resistant strains 

(10,13). Widespread use of antimicrobials in veterinary 

medicine has resulted in the emergence 

Table 2. Number of strains according to level of resistance to erythromycin and ciprofloxacin* 

Origin of isolates 

(No) 

Species (No) 

of strains of Campylobacter displaying a MDR 

phenotype (26). These strains are transmitted to 

humans usually through the consumption of undercooked 

contaminated food, particularly poultry. 

Of concern to public health is the increase in 

strains resistant to fluoroquinolone and macrolide 

drugs, important antibiotics used in the front-line 

treatment of campylobacteriosis (27). 

The results of our study do not show a significant 

difference in ciprofloxacin-resistance 

between domestic and imported poultry meat 

samples. We have got a confirmation of the examined 

farm owner that no antibiotics were applied 

to animal food, but still there is a possibility 

for an increase in their use for therapeutic purposes 

instead (28). The fact that the decrease of 

fluoroquinolone-resistant campylobacters had 

been observed before and during the use of antimicrobial 

growth promoters suggests that other 

factors might be involved (29). 

The reports about the connection between 

individual fluoroquinolone used in humans and 

development of fluoroquinolone-resistance in 

Campylobacter isolates are still controversial 

(4,10,12). It is worth mentioning that 56.6% of 

isolates from this study and 67% isolates from 

the previous study (11), all from the Zenica- 

Doboj region, originated from children up to 6 

years old. High ciprofloxacin-resistance in this 

age group (23.3%) was found and due to the fact 

that the use of quinolones is restricted for children, 

the high ciprofloxacin-resistance is probably 

not influenced by overuse of this drug. It is 

unlikely that the human use of fluoroquinolones 

alone could be responsible for high-resistance 

rates of human Campylobacters to fluoroquinolones 

observed in many countries (4,10,12). Our 

results indicate the resistance of an animal origin 

No of strains inhibited at MIC(µg/mL) of erythromycin: 

No of strains inhibited at 

MIC(µg/mL) of ciprofloxacin: 

512 32 

Human (52) C. jejuni (37) 23 3 2 3 3 3 24 12 1 

C. coli (15) 12 2 1 11 4 

Retail poultry (51) C. jejuni (22) 12 1 1 3 4 15 1 6 

C. coli (29) 19 1 1 3 3 2 24 1 4 

Poultry (15) C. jejuni (7) 4 3 4 3 

C. coli (8) 7 1 6 1 

*cutoff values: erythromycin MIC ≥ 32 mg/L; ciprofloxacin MIC ≥ 4mg/L; 


177

178 


rather than the overuse of these drugs in humans 

as proposed previously (12). Antibiotic-sensitive 

bacteria that are gradually exposed to increasing 

concentrations of a given antibiotic develop increasing 

resistance to that antibiotic and that induces 

the resistance increase to other unrelated 

antibiotics. The development of a MDR phenotype 

suggests that the development of multidrug 

resistance in Gram-negative bacteria in patients 

treated with subinhibitory doses of the antibiotic 

occurs via the same mechanism (30). 

The prevalence of erythromycin-resistance for 

human isolates (32.1%) reported in this study has 

surpassed the usually reported rates (

and Science of Bosnia and Herzegovina, as well 

as the Ministry of the Flemish Community for the 

financial support of the project and authors bilateral 

cooperation. 

This study was presented as part of: Uzunovic-Kamberovic 

S, Zorman T, Herman L, 

Berce I, Smole-Mozina S. Campylobacter jejuni 

REFERENCES 

1. Tauxe RV. Emerging foodborne pathogens. Internat 

J Food Microbiol 2002; 78:31-41. 

2. Workman SN, Mathison GE, Lavoie MC. Pet 

dogs and chicken meat as reservoirs of Campylobacter 

spp. in Barbados. J Clin Microbiol 2005; 

43:2642-50. 

3. Sacks JJ, Lieb S, Baldy LM, Berta S, Patton CM, 

White MC, Bigler WJ, Witte JJ. Epidemic campylobacteriosis 

associated with a community water 

supply. Am J Public Health 1986; 76:424-8. 

4. Gallay A, Prouzet-Mauléon V, Kempf I, Lehours 

P, Labadi L, Camou C, Denis M, de Valk H, Desenclos 

JC, Mégraud F. Campylobacter antimicrobial 

drug resistance among humans, broiler 

chickens, and pigs, France. Emerg Infect Dis 

2007; 13:259-66. 

5. Zorman T, Smole Mozina S. Classical and molecular 

identification of thermotolerant campylobacters 

from poultry meat. Food Technol Biotechnol 

2002; 40:177-84. 

6. Corry JEL, Atabay HI. Poultry as a source of 

Campylobacter and related organisms. J Appl 

Microbiol 2001; 90:90S-114S. 

7. Stafford RJ, Schluter PJ, Wilson AJ, Kirk MD, 

Hall G, Unicomb L; OzFoodNet Working Group. 

Population-attributable risk estimates for risk factors 

associated with Campylobacter infection, 

Australia. Emerg Infect Dis 2008; 14:895-901. 

8. Hopkins KL, Desai M, Frost JA, Stanley J, Logan 

JM. Fluorescent amplified fragment length polymorphism 

genotyping of Campylobacter jejuni 

and Campylobacter coli strains and its relationship 

with host specificity, serotyping, and phage 

typing. J Clin Microbiol 2004; 42:229-35. 

9. Uzunovic-Kamberovic S, Zorman T, Heyndrickx 

M, Smole Mozina S. Role of poultry meat in sporadic 

Campylobacter infections in Bosnia and 

Herzegovina: laboratory-based study. Croat Med 

J 2007; 48:844-53. 

10. Smith KE, Besser JM, Hedberg CW, Leano FT, 

Bender JB, Wicklund JH, Johnson BP, Moore 

KA, Osterholm MT. Quinolone-resistant Campylobacter 

jejuni infections in Minnesota, 1992- 

1998. New Engl J Medicine 1999; 340:1525-32. 


and C. coli resistance in humans, poultry products 

and farm chickens: an epidemiological and 

laboratory study. Proceeding of the 14 th European 

Congress of Clinical Microbiology and Infectious 

Diseases, Prague, Chek, May 1-4, 2004. 

Clin Microbiol Infect 2004; 10 (Suppl 3):195. 

Competing interests: none decleared 

11. Uzunovic-Kamberovic S: Antibiotic susceptibility 

of Campylobacter jejuni and Campylobacter 

coli human isolates from Bosnia and Herzegovina. 

J Antimicrob Chemother 2003; 51:1049-51. 

12. Gupta A, Nelson JM, Barrett TJ, Tauxe RV, Rossiter 

SP, Friedman CR, Joyce KW, Smith KE, 

Jones TF, Hawkins MA, Shiferaw B, Beebe JL, 

Vugia DJ, Rabatsky-Ehr T, Benson JA, Root TP, 

Angulo FJ; NARMS Working Group. Antimicrobial 

resistance among Campylobacter strains, 

United States, 1997-2001. Emerg Infect Dis 2004; 

10:1102-9. 

13. Van Looveran M, Daube G, De Zutter L, Dumont 

J-M, Lammens C, Wijdooghe M, Vandamme P, 

Jouret M, Cornelis M, Goossens H. Antimicrobial 

susceptibilities of Campylobacter strains isolated 

from food animals in Belgium. J Antimicrob 

Chemother 2001; 48:235-40. 

14. Aarestrup MF, Nielsen EM, Madsen M, Engberg 

J. Antimicrobial susceptibility patterns of 

thermophilic Campylobacter spp. from humans, 

pigs, cattle and broilers in Denmark. Antimicrob 


15. Uzunovic-Kamberovic S. Changes in Campylobacter 

jejuni / Campylobacter coli carriage rates 

in the Zenica region of Bosnia and Herzegovina 

in the pre- and postwar periods. J Clin Microbiol 

2001; 39:2036. 

16. Uzunovic-Kamberovic S. Some epidemiologic 

features of Campylobacter jejuni/coli infections 

in Bosnia and Herzegovina after the war. Clin 

Microbiol Infect 2003; 9: 458-60. 

17. Nielsen EM, Engberg J, Madsen M. Distribution 

of serotypes of Campylobacter jejuni and C. coli 

from Danish patients, poultry, cattle and swine. 

FEMS Immunol Med Microbiol 1997; 19:47-56. 

18. Zorman T, Heyndrickx M, Uzunovic-Kamberovic 

S, Smole Mozina S. Genotyping of Campylobacter 

coli and C. jejuni from retail chicken meat 

and humans with campylobacteriosis in Slovenia 

and Bosnia and Herzergovina. Intern J Food 

Microbiol 2006; 110:24-33. 

19. Smibert, RM: Genus Campylobacter Sebald and 

Véron 1963. In Bergey`s Manual of Systematic 

Bacteriology. Krieg NR, Holt JG, eds. Baltimore: 

Williams & Wilkins; 1984:11-118. 

179

180 


20. Clinical and Laboratory Standards Institute. 

Methods for antimicrobial dilution and disk susceptibility 

testing of infrequently isolated bacteria. 

Approved guideline M45-A. Philadelphia: 

CLSI, Wayne, 2006. 

21. Kurincic M, Berce I, Zorman T, Smole Mozina S. 

The prevalence of multiple antibiotic resistance 

in Campylobacter spp. from retail poultry meat. 

Food Technol Biotechnol 2002; 43:157-163. 

22. Luber P, Bartelt E, Genschow E, Wagner J, Hahn 

H. Comparision of broth microdilution, E-test and 

agar dilution methods for antibiotic susceptibility 

testing of Campylobacter jejuni and Campylobacter 

coli. J Clin Microbiol 2003; 41:1062-8. 

23. Thwaites RT, Frost JA. Drug resistance in Campylobacter 

jejuni, C. coli, and C. lari isolated from 

humans in North West England and Wales, 1997. 

J Clin Pathol 1999; 52:812-4. 

24. Oza AN, McKenna JP, McDowell SWJ, Menzies 

FD, Neill SD. Antimicrobial susceptibility of 

Campylobacter spp. isolated from broiler chickens 

in Nothern Ireland. J Antimicrob Chemoth 

2003; 52:220-3. 

25. Wittwer M, Keller J, Wassenaar TM, Stephan R, 

Howald D, Regula G, Bissig-Choisat B. Genetic 

diversity and antibiotic resistance patterns in a 

Campylobacter population isolated from poultry 

farms in Switzerland. Appl Environ Microbiol 

2005; 71:2840-7. 

26. Aarestrup FM, Engberg J. Antimicrobial resistance 

of thermophilic Campylobacter. Vet Res 

2001; 32:311-21. 

27. Quinn T, Bolla J-M, Pages J-M, Fanning S. Antibiotic-resistant 

Campylobacter: could efflux 

pump inhibitors control infection. J Antimicrob 

Chemother 2007; 59:1230-6. 

28. Soonthornchaikul N, Garelick H, Jones H, Jacobs 

J, Ball D, Choudhury M. Resistance to three antimicrobial 

agents of Campylobacter isolated 

from organically- and intesively-reared chickens 

purchased from retail outlets. Int J Antimicrob 


29. Evans MC, Wegener H. Antimicrobial growth 

promoters and Salmonella spp., Campylobacter 

spp. in poultry and swine, Denmark. Emerg Infect 

Dis 2003; 9:489-92. 

30. Martins A, Couto I, Aagaard L, Martins M, 

Viveiros M, Kristiansen JE, Amaral L. Prolonged 

exposure of methicillin-resistant Staphylococcus 

aureus (MRSA) COL strain to increasing concentartion 

of oxacillin results in a multidrug-resistant 

phenotype. Int J Antimicrob Agents 2007; 

29:302-5. 

31. Engberg J, Aarestrup FM, Taylor DE, Gomer- 

Schmidt P, Nachamkin I. Quinolone and macrolide 

resistance in Campylobacter jejuni and 

Campylobacter coli: resistance mechanisms and 

trends in human isolates. Emerg Infect Dis 2001; 

7:24-34. 

32. Rao D, Rao JR, Crothers E, McMulan R, McDowell 

D, McMahon A, Rooney PJ, Millar BC, Moore 

JE. Increased erythromycin resistance in clinical 

Campylobacter in Northern Ireland-an update. J 

Antimicrob Chemother 2005; 55:395-6. 

33. Senok A, Yousif A, Mazi W, Tocque K, O’Brien 

S, Regan M, Elnima el-A, Botta G. Pattern of 

antibiotic susceptibility in Camyplobacter jejuni 

isolates of human and poultry origin. Jpn J Infect 

Dis 2007; 60:1-4. 

34. Unicomb L, Ferguson J, Stafford RJ, Ashbolt 

R, Kirk MD, Becker NG, Patel MS, Gilbert GL, 

Valcanis M, Mickan L; Australian Campylobacter 

Subtyping Study Group. Low-level fluoroquinolone 

resistance among Campylobacter 

jejuni isolates in Australia. Clin Infect Dis 2006; 

42:1368-74. 

35. Centers for Disease Control and Prevention 

(CDC). Outbreak of Campylobacter jejuni infections 

associated with drinking unpasteurized 

milk procured through a cow-leasing program – 

Wiskonsin, 2001. Morb Mortal Wkly Rep 2002; 

51: 548-9. 

36. Parisi A, Lanzilotta SG, Addante N, Normanno 

G, Di Modugno G. Prevalence, molecular characterization 

and antimicrobial resistance of thermophilic 

Campylobacter isolates from cattle, 

hens, broilers and broiler meat in south-eastern 

Italy. Wet Res Comm 2007; 31:113-23. 

37. Cardinale E, Dromigny J-A, Tall F, Ndiaye M, 

Konte M, Perrier-Gros-Claude JD. Fluoroquinolone 

susceptibility of Camyplobacter strains, 

Senegal. Emerg Infect Dis 2003; 9:1479-81. 

38. Cagliero C, Cloix L, Cloeckeart A, Payot S. High 

genetic variation in the multidrug transporter 

cmeB gene in Campylobacter jejuni and Campylobacter 

coli. J Antimicrob Chemother 2006; 

58:168-72. 

39. Kurinčić M, Botteldoom N, Herman L. Mechanisms 

of erythromycin resistance of Campylobacter 

spp. isolated from food, animals and humans. 

Int J Food Microbiol 2007; 30:186-90.


Atelektaza pluća i infekcije donjih dišnih puteva u djece na odjelu 

za intenzivno liječenje 

Nada Mladina¹, Devleta Hadžić¹, Amela Selimović² 

¹Klinika za dječije bolesti, ²Klinika za ginekologiju i akušerstvo; Univerzitetski klinički centar Tuzla, Bosna i Hercegovina 


Nada Mladina, 

Klinika za dječije bolesti, 

Univerzitetski klinički centar Tuzla, 

Trnovac bb, 75000 Tuzla, 

Bosna i Hercegovina 

Phone: ++387 35 303 713 

E-mail: nada.m@bih.net.ba 


22. juli 2008.; 


25. oktobar 2008.; 

Prihvaćeno: 

08. novembar 2008. 

Med Glas 2009; 6(2): 181-187 

SAŽETAK 

Cilj rada Prikazati etiološke, kliničke i radiološke karakteristike 

atelektaze pluća kod djece na intenzivnom tretmanu u Odjeljenju 

intenzivne njege i terapije Klinike za dječije bolesti Tuzla u 

jednogodišnjem periodu. 

Metode Uzorak je obuhvatio 31 dijete sa infekcijom donjih dišnih 

puteva i atelektazom pluća. Prosječna dob djece iznosila je 3,6 ± 

3,9 g. Analizirane su etiološke, kliničke i radiološke karakteristike 

atelektaze pluća kod djece sa infekcijom donjih dišnih puteva. 

Rezultati U promatranom jednogodišnjem periodu zbog infekcija 

donjih dišnih puteva, bronhitisa i pneumonije, liječeno je ukupno 

332 pacijenta, od čega 208 dječaka (62,7%) i 124 djevojčice 

(37,3%). Kod 224 (67,5%) pacijenta radiološki nalaz je pokazao 

pneumoniju, dok je kod 31 (9,3%), uz pneumoniju, opisana 

i atelektaza pluća. Najčešća je bila desnostrana atelektaza (20 ili 

64,5%), dok je u 10 ili 32,3% registrovana lijevostrana, a kod 

jednog pacijenta (3,2%) obostrana. Općenito osnovno oboljenje 

bila je infekcija donjih dišnih puteva (30 ili 96,8%), dok je kod 

samo jednog pacijenta to bio medijastinalni ekspanzivni proces. 

Klinički znaci, nalazi gasnih analiza i pulsne oksimetrije, bili su u 

korelaciji i u smislu hipoksemijskog tipa respiratorne insuficijencije. 

Najčešći uzrok atelektazi pluća bila je staza gustog sekreta, 

koja je dovela do smetnji ventilacije. Kontinuiranu oksigenoterapiju 

zahtijevalo je svih 31 pacijenata, najmanje 24 sata, dok je 

monitoring vitalnih parametara kod 12 ili 38,7% pacijenata bio 

potreban duže od 24 sata. Prosječna dužina intenzivnog liječenja 

bila je 4,3 ± 2,7 dana (od 1 do 15 dana). 

Zaključak Atelektaze pluća kod djece sa infekcijama donjih 

dišnih puteva u odjeljenju intenzivne njege nisu rijetke. One predstavljaju 

dodatni faktor rizika za ozbiljne poremećaje plućne ventilacije, 

naročito u dojenačkoj dobi. 

Ključne riječi: atelektaza pluća, donji dišni putevi, dijete 

181

182 


UVOD 

Atelektaza pluća predstavlja poremećaj plućne 

ventilacije u kojem manji ili veći dio plućnog 

parenhima nije u stanju da se ispuni vazduhom. 

Ovaj poremećaj može da se manifestuje odmah 

poslije rođenja, kao urođena totalna ili parcijalna 

atelektaza, ili kasnije, tokom života, kao stečena 

atelektaza (1). Atelektaza nije bolest za sebe već 

posljedični poremećaj ventilacije pluća nastao 

zbog niza bolesti i poremećaja. Uzroci atelektaze 

su brojni. Najčešće je to opstrukcija bronha koja 

može biti intraluminalna, muralna i ekstramuralna 

(2). Neke bolesti, kao što su astma, cistična 

fibroza, neuromuskularne bolesti i dr., uključuju i 

razvoj atelektaze. (3, 4). Poremećaji plućne ventilacije 

naročito su česti kod djece mlađe od pet 

godina, s obzirom da i minimalne promjene u disajnim 

putevima u tom uzrastu mogu da dovedu do 

opstrukcije disajnog puta (1, 2). Atelektaza može 

da protiče asimptomatski i da se otkrije tokom rutinskog 

fizikalnog ili radiološkog pregleda, a može 

biti i vrlo dramatična, naročito kod aspiracije stranog 

tijela u disajnim putevima (1, 2). Klinička 

slika zavisi od veličine atelektaze, a fizikalni nalaz 

i od primarne bolesti koja je doprinijela njenom 

razvoju. Rentgenski snimak pluća je ‘’zlatni 

standard’’ za dijagnozu atelektaze (5, 6). Fleksibilna 

bronhoskopija korisna je u dijagnostici i u 

liječenju atelektaze (7). Atelektaza može nastati 

i posredstvom refleksnog bronhospazma uslijed 

bola, prijeloma rebara, hirurških intervencija na 

abdomenu i toraksu, te dijagnostičkih i drugih procedura, 

kao što su bronhoskopija, bronhografija, 

anestezija i drugo (8-10). Prognoza i tretman zavise 

od uzroka atelektaze. Dijagnostika i liječenje 

moraju biti uzročno usmjereni (2, 6, 8). 

Cilj ovog istraživanja bila je analiza 

učestalosti, te etioloških, kliničkih i radioloških 

karakteristika atelektaza pluća kod djece na intenzivnom 

tretmanu radi infekcija donjih dišnih 

puteva u jednogodišnjem periodu. 

ISPITANICI I METODE 

Retrospektivnim istraživanjem analizirani 

su svi pacijenati liječeni na Odjeljenju intenzivne 

njege i terapije Klinike za dječije bolesti u Tuzli, 

sa radiološki i klinički potvrđenom atelektazom 

pluća, u periodu 1. 01. 2006. do 31. 12. 2006. godine. 

Izvor podataka bio je protokol Odjeljenja 

intenzivne njege Klinike za dječije bolesti, kao i 

istorije bolesti liječenih pacijenata. Analizirani su 

anamnestički podaci, klinički i laboratorijski nalazi, 

terapijski postupci, dužina boravka u Odjeljenju 

intenzivne njege i terapije, te ishod liječenja. Od 

anamnestičkih podataka analiza je obuhvatala 

mjesto stanovanja, broj hospitalizacijâ, sezonsku 

distribuciju hospitalizacije, te vodeće kliničke 

simptome. Od kliničkog nalaza analizirani su 

uzrast, spol djeteta, opći pedijatrijski nalaz, lokalni 

auskultatorni nalaz, vitalni parametri (frekvenca 

pulsa, broj respiracija, tjelesna temperatura, saturacija 

krvi kisikom, mjerena pulsnim oksimetrom). 

Od laboratorijskih parametara analizirani su biohemijski 

nalazi: sedimentacija eritrocita, kompletna 

krvna slika i hematokrit, C-reaktivni protein, gasne 

analize, radiološki nalazi i mikrobiološke analize. 

Sve navedene pretrage rađene su na Poliklinici za 

laboratorijsku dijagnostiku, Zavodu za radiologiju 

i Zavodu za mikrobiologiju Univerzitetskog kliničkog 

centra Tuzla. Od terapijskih postupaka 

posebno je analizirana primjena i vremenski period 

oksigenoterapije sa visokim protokom kisika, inhalatorne 

terapije bronhodilatatorima, antibiotske terapije, 

sistemske primjene kortikosteroida, potrebe 

za primjenom kardiotonika i diuretika, rehidratacije 

kristaloidima, otvaranja dišnog puta, upotrebe 

balona sa maskom, primjene mehaničke ventilacije, 

dužine liječenja u Odjeljenju intenzivne njege i 

terapije, kao i ishodi liječenja. 

U statističkoj obradi rezultata korištene su 

standardne metode deskriptivne statistike. 

REZULTATI 

U periodu od 1. 01. 2006. do 31. 12. 2006. u 

Odjeljenju intenzivne njege i terapije Klinike za 

dječije bolesti Tuzla liječeno je ukupno 767 djece. 

Zbog respiratornih bolesti liječeno je 332 djece, 

od čega 208 dječaka (62,7% ) i 124 djevojčice 

(37,3%). Radiološki nalaz bio je uredan kod 108 

pacijenata (32,5%). Kod 224 pacijenta (67,5%)

Tabela 1. Dob pacijenata liječenih zbog atelektaze pluća 

Dob (godine) 

Ukupno 

( n = 31) 

Dječaci 

( n = 18) 

Djevojčice 

( n = 13) 

0-1 13 (41,9) 6 7 

1-3 5 (16,1) 2 3 

3-7 6 (19,4) 4 2 

7-14 7 (22,6) 6 1 

radiološki je opisana pneumonija, od toga kod 100 

pacijenata (44,6%) desnostrana, kod 22 (9,8 %) lijevostrana, 

a kod 102 pacijenta (45,5%) obostrana 

pneumonija. Atelektaza pluća radiološki je verificirana 

kod 31 pacijenta, uzrasta od 2,5 mjeseca 

do 12,9 godina. Prosječna dob te djece iznosila je 

3,60 ± 3,96 godine. Odnos dječaka i djevojčica 

iznosio je 1,4 : 1. Najveći broj pacijenata bio je 

dojenačke dobi u kojoj je distribucija po spolu 

bila ujednačena, dok su u starijim dobnim skupinama 

dominirali dječaci (Tabela 1). 

Prvu hospitalizaciju zbog respiratornog 

oboljenja imalo je 18 pacijenata (58,1%), a njih 

13 (41,9%) sa radiološki verificiranom atelektazom 

pluća imalo je više rehospitalizacija zbog 

respiratorne bolesti. Najveći broj pacijenata 

sa radiološki verificiranom atelektazom pluća 

zabilježen je u mjesecu decembru (12; 38,7%), 

potom u mjesecima maju i junu (po 5 pacijenata; 

16,1%). Najviše liječenih pacijenata bilo je iz Tuzle, 

(12; 38,7%), potom iz Lukavca i Banovića 

(po 5 pacijenata; 16,1%). U Tabeli 2. prikazane 

su prateće bolesti i stanja koja su dijagnosticirana 

kod pacijenata liječenih zbog atelektaze pluća. 

Uz atelektazu pluća, najčešće su zabilježene 

infekcije donjih dišnih puteva, bronhitis i pneumonija 

(kod 30 pacijenata), dok je jedan pacijent 

imao ekspanzivni medijastinalni proces. Pacijenti 

sa ponavljanim hospitalizacijama zbog respiratornih 

bolesti imali su obično prateća hronična 

oboljenja, najčešće imunodeficijenciju, anemiju, 

urođene srčane greške, neuromišićne i neurorazvojne 

bolesti. Lokalizacija atelektaze bila je 

Tabela 3. Vitalni parametri kod djece sa atelektazom pluća 

Parametar 

Mean ± 

SD* 

Minimum 

Maksimum 

Median 

Puls 134 ± 15 100 160 136 

Broj respiracija 42 ± 13 20 65 42 

Tjelesna temperatura 

(°C) 

37,6 ± 0,74 36,4 39,4 37,5 

Pulsna 

oksimetrija (%) 

93 ± 3 85 95 95 

*aritmetička sredina ± standardna devijacija 

Mladina et al Atelektaza pluća i infekcije donjih dišnih puteva u djece 

Tabela 2. Prateće bolesti i stanja dijagnosticirana kod pacijenata 

liječenih zbog atelektaze pluća 

Prateće bolesti i stanja Broj pacijenata* (%) 

Bronhitis 20 (43,5) 

Pneumonija 10 (21,7) 

Imunodeficijencija 5 (10,9) 

Anemija 4 (8,7) 

Urođene srčane greške 2 (4,3) 

Neuromišićne bolesti 2 (4,3) 

Neurorazvojne bolesti i poremećaji 2 (4,3) 

Limfom 1 (2,2) 

*neki pacijenti imali su više od jednog favorizirajućeg faktora za 

nastanak atelektaze pluća 

najčešće u desnom plućnom krilu (kod 20 pacijenata; 

65%), u lijevom (kod 10 pacijenata; 32%), a 

samo kod jednog pacijenta bila je prisutna obostrana 

atelektaza pluća. 

Klinički atelektaza pluća kod naših ispitanika 

karakterizirala se znacima dispneje i povećanog 

rada pluća (tahipneja, tahikardija), hipoksemijom 

potvrđenom sniženim vrijednostima saturacije 

krvi kisikom, te znacima prijeteće respiratorne insuficijencije. 

Vitalni parametri pacijenata sa atelektazom 

u našem uzorku prikazani su u Tabeli 3. 

Vitalni parametri (puls i broj respiracija) pacijenata 

sa atelektazom, u našem uzorku, pokazali 

su odstupanje i bili većih vrijednosti u odnosu na 

normalne vrijednosti za dječiju dob. U Tabeli 4 

prikazane su vrijednosti pulsa i broja respiracija 

pacijenata s atelektazom pluća po pojedinim 

dobnim skupinama i u poređenju sa normalnim 

vrijednostima za dob. 

Tabela 4. Vitalni parametri pacijenata s atelektazom pluća 

po pojedinim dobnim skupinama 

Dob (godine) 0-1 1-3 3-7 7-14 

Puls 

(u min.) 

Respiracije 

(u min.) 

minimalno 

maksimalno 

126 120 120 100 

160 150 136 144 

mean 146,7 136 124,3 120,6 

normalno 

minimalno 

maksimalno 

110-160 100-140 95-120 60-110 

26 42 24 10 

65 60 52 48 

mean 49,3 47,6 36 29,4 

normalno 

30-40 25-30 20-25 15-20 

183

184 


U Tabeli 5 prikazani su parametri acidobaznog 

statusa i gasnih analiza pacijenata s atelektazom 

pluća. 

Rezultati osnovnih laboratorijskih parametara 

krvne slike, sedimentacije eritrocita i nalaza 

C-reaktivnog proteina prikazani su u Tabeli 6. 

U 20 pacijenata (64,5%) vrijednost Creaktivnog 

proteina kod prijema bila je iznad 10 

mg/L. Broj leukocita kod prijema bio je u 14 

pacijenata (45,2%) iznad 15 x 10 9 /L, a 13 je pacijenata 

(41,9%) bilo febrilno kod prijema, sa izmjerenom 

tjelesnom temperaturom iznad 38 °C. 

Mikrobiološka analiza pokazala je pozitivne 

kulture brisa ždrijela i nosa kod 9 (29,0%), odnosno 

kod 3 (9,7%) pacijenta. Najčešće su bili izolirani 

Staphylococcus aureus (5 izolata), Klebsiella 

spp. (4 izolata), te Pseudomonas aeruginosa, Candida 

albicans i Mycobacterium tuberculosis (po 1 

izolat). Nije bilo pozitivnih nalaza hemokulture. 

Oksigenoterapija tokom najmanje 24 sata, 

primijenjena je kod svih (31) pacijenata. Monitoring 

vitalnih parametara duži od 24 sata, zahtijevalo 

je 12 pacijenata (38,7%). Antibiotska 

parenteralna terapija, terapija bronhodilatatorima 

i intenzivna respiratorna fizikalna terapija 

s ciljem drenaže bronhalnog sekreta, primijenjena 

je kod svih (31) pacijenata. Kardiotonike, 

u okviru terapijskog tretmana, zahtijevalo je 13 

pacijenata (41,9%). Najveći broj pacijenata, koji 

su imali manifestne znake srčanog popuštanja i 

zahtijevali u terapiji kardiotonike i diuretike, bila 

su dojenčad; osam pacijenata (61,5%). U jednog 

pacijenta bila je indicirana terapijska bronhoskopija 

i drenaža. Pacijent sa dijagnosticiranim malignim 

procesom u medijastinumu podvrgnut 

Tabela 5. Parametri acidobaznog statusa pacijenata s 

atelektazom 

Parametar Mean ± SD* 

Minimum 

Maksimum 

Median 

pH 7,35 ± 0,07 7,08 7,47 7,35 

pCO2 (kPa) 4,99 ± 0,96 2,64 7,49 4,9 

pO2 (kPa) 6,62 ± 1,27 3,59 8,6 6,85 

Bazni višak -2,4 ± 4 -14 2,5 -1,4 

Bikarbonati 

(mmol/ℓ) 

21 ± 3,6 10 28 21,25 

Saturacija 

kisikom (%) 

78 ± 12 45,2 90 80 

*aritmetička sredina ± standardna devijacija 

je odgovarajućoj terapiji prema usvojenim protokolima. 

Prosječna dužina liječenja u Odjeljenju intenzivne 

njege bila je 4,3 ± 2,7 dana (od 1 do 15 

dana), a prosječna dužina ukupnog bolničkog tretmana 

bila je 14,6 ± 11,4 dana (od 5 do 57 dana). 

DISKUSIJA 

Dobna distribucija pacijenata sa atelektazom 

pluća u našem istraživanju pratila je dobnu 

distribuciju ukupnog uzorka pacijenata sa respiratornim 

bolestima, što se uglavnom slaže sa 

podatkom da su, uz atelektazu pluća, najčešće 

zabilježene infekcije donjih dišnih puteva, bronhitis 

i pneumonija, kao i sa podacima iz literature 

(1-3). Distribucija po spolu pacijenata sa 

atelektazom u našem istraživanju razlikovala se 

u odnosu na ukupni uzorak pacijenata sa respiratornim 

bolestima. Nasuprot prednosti dječaka u 

ukupnom uzorku respiratornih bolesti, koja je u 

dojenačkom periodu najizrazitija, u našem uzorku 

pacijenata sa atelektazom pluća ustanovljena je 

minimalna prednost djevojčica u dojenačkom 

periodu. Ovu razliku teško je objasniti, čak i kad 

se uzmu u obzir i prateće bolesti i stanja koja su 

zabilježena kod naših pacijenata sa atelektazom. 

Mogući razlog mogao bi biti i relativno kratak 

period istraživanja. 

Pacijenti sa ponavljanim hospitalizacijama 

zbog respiratornih bolesti, u našem istraživanju 

imali su obično prateća hronična oboljenja, 

najčešće imunodeficijenciju, anemiju, urođene 

srčane greške, neuromišićne i neurorazvojne 

Tabela 6. Laboratorijski pokazatelji pacijenata sa atelektazom 

Parametar 

Sedimentacija 

eritrocita 

C-reaktivni 

prot. (mg/L) 

Hemoglobin 

(g/L) 

Broj eritrocita 

(x1012/L) 

Broj leukocita 

(x109/L) 

Hematokrit 

(L/L) 

Mean ± 

SD* 

Minimum 

Maksimum 

Median 

33 ± 27 5 110 30 

37 ± 56 0,1 249 17,5 

116 ± 16 75 148 119 

4,23 ± 0,52 3,2 5,4 4,2 

14,4 ± 5,4 5,2 27 13,7 

0,34 ± 0,04 0,27 0,4 0,34

olesti. Sva ova stanja obično podrazumijevaju 

teškoće sa disanjem i hranjenjem, što donekle 

može objasniti češću zastupljenost pacijenata sa 

ovim hroničnim bolestima i poremećajima među 

pacijentima sa atelektazom pluća. Ovo se uglavnom 

slaže sa rezultatima sličnih istraživanja 

(3, 4, 6). Sezonska distribucija pacijenata sa atelektazom 

pratila je sezonsku distribuciju ukupnog 

uzorka pacijenata sa respiratornim bolestima. 

Klinička slika zavisi od veličine područja 

zahvaćenog atelektazom (1-3). U našem 

istraživanju, kliničke karakteristike pacijenata sa 

atelektazom pluća uglavnom su bili znaci dispneje 

i povećanog rada pluća (tahipneja, tahikardija), 

što se slaže sa činjenicom da je u našem uzorku 

najčešći uzrok atelektazi pluća (kod 96,8%) najvjerovatnije 

bila staza sekreta u pacijenata sa 

bronhitisom i pneumonijom, dok je kod jednog 

pacijenta (3,2%) atelektaza bila uzrokovana kompresijom 

tumorskih masa iz medijastinuma. Podaci 

iz literature značajno se razlikuju od ustanove do 

ustanove (2-7) i uglavnom su ovisni o patologiji 

koju određeni zdravstveni centar zbrinjava. Našim 

istraživanjem nisu obuhvaćeni pacijenti sa stranim 

tijelom u bronhima jer se oni, po organizaciji posla, 

liječe u Klinici za otorinolaringologiju. 

Fizikalni nalaz, također, zavisi od primarne 

bolesti koja je doprinijela razvoju atelektaze 

(1-3). Mada je atelektaza uglavnom mehaničkog 

porijekla, vrlo često postoje znaci bakterijske 

infekcije, što najviše zavisi od primarnog 

plućnog poremećaja (9, 15-19). Atelektaze su 

vrlo podložne i sekundarnim bakterijskim infekcijama 

(9, 14). Nespecifični markeri upale 

(sedimentacija eritrocita, C-reaktivni protein i 

leukociti) imaju ograničeno značenje pri dijagnosticiranju 

bakterijskih infekcija kod djece s 

atelektazom. Ipak, značajno je istaći da se vrlo 

visoke vrijednosti pojedinih upalnih markera rijetko 

viđaju pri virusnim infekcijama (15-17). 

Lala i saradnici (18) ustanovili su kako se kod 

djece sa pneumonijom nalaz CRP-a veći od 10 

mg/l signifikantno češće javlja u grupi djece s 

bakterijskim pneumonijama u odnosu na ostale 

uzročnike. Slične rezultate objavili su Bircan i 

saradnici (19). U našem istraživanju našli smo 


umjereno povišene biohemijske parametre bakterijske 

infekcije. Najčešće izolovani bakterijski 

uzročnici u našem istraživanju bili su Staphylococcus 

aureus i Klebsiella spp. što govori o populaciji 

našeg uzorka, s obzirom da ovi uzročnici 

više odgovaraju etiologiji bolničkih pneumonija 

i pneumonija kod imunodeficijentnih pacijenata. 

Podaci iz literature su različiti, a rezultati slični 

našima, objavljeni su u nekoliko studija (14, 20). 

Liječenje pacijenata sa atelektazom pluća zavisi 

od njezinog uzroka (6). U slučaju aspiracije i 

stranog tijela u disajnim putevima, terapija izbora 

je bronhoskopska evaluacija, evakuacija stranog 

sadržaja i drenaža. Fizikalna terapija općenito je od 

posebnog značaja i koristi. Drenaža sekreta je osnovna 

mjera i cilj terapije bilo koje endobronhalne 

opstrukcije (20). Smatra se da je kod atelektaze, 

koja traje duže od godinu dana, proces na plućima 

ireverzibilan i da je u tom slučaju indicirano 

hirurško liječenje (22). U našem istraživanju, 

tokom jednogodišnjeg perioda, u jednog pacijenta 

bila je indicirana terapijska bronhoskopija i 

drenaža, dok mehaničku potporu disanju i hirurško 

liječenje nije bilo neophodno primijeniti ni kod 

jednog djeteta sa atelektazom pluća. 

Analiza učestalosti atelektaze pluća kod 

djece sa infekcijama donjih dišnih puteva, koja su 

zahtijevala intenzivni nadzor i tretman, pokazala 

je da je učešće atelektaza kao precipitirajućeg 

faktora poremećaja plućne ventilacije značajno, 

naročito u dojenačkoj populaciji. Atelektaza 

pluća kod ovih pacijenata klinički je odgovarala 

slici osnovnog oboljenja. Blagovremena dijagnostika, 

kao i energične mjere liječenja infekcije 

donjih dišnih puteva, uz adekvatan fizikalni tretman, 

kod većine pacijenata u našem istraživanju 

bile su dovoljne za uspješno terapijsko rješavanje 

nastalog poremećaja plućne ventilacije. Kod 

tumačenja ovih rezultata svakako treba uzeti u 

obzir i kratak period istraživanja, te su potrebna 

daljnja prospektivna istraživanja koja će obuhvatiti 

veći broj pacijenata. 

ZAHVALE / IZJAVE 

Komercijalni ili potencijalni dvostruki interes 

ne postoji. 

185

186 


LITERATURA 

1. Šićević S. Atelektaza pluća. U: Plućne bolesti u 

dece. Savremena administracija. Beograd 1990; 

312-1. 

2. Raos M, Klancir SB, Dodig S, Kovač K. Atelektaze 

pluća u dječjoj dobi. Paediatr Croat 1999; 

43: 95-99. 

3. Peroni DG, Boner AL. Atelectasis: mechanisms, 

diagnosis and management. Pediatr Respir Rev 

2000; 1: 274-8. 

4. Birnkrant DJ. The assessment and management 

of the respiratory complications of pediatric neuromuscular 

diseases. Clin Pediatr (Phila) 2002; 

41: 301-8. 

5. Ashizawa K, Hayashi K, Aso N, Minami K. Br J 

Radiol 2001; 74: 89-97. 

6. Schindler MB. Treatment of atelectasis: where is 

the evidence? Crit Care 2005; 9: 341-2. 

7. Holmgren NL, Cordova M, Ortuzar P, Sanchez I. 

Role of flexible bronchoscopy in the re-expansion 

of persistent atelectasis in children. Arch Bronconeumol 

2002; 38: 367-71. 

8. Hendriks T, de Hoog M, Lequin MH, Devos AS, 

Merkus PJ. Crit Care 2005; 9: 351-6. 

9. Riccetto AG, Zambom MP, Pereira IC, Morcillo 

AM. Influence of socioeconomic and nutritional 

factors on the evolution to complications in children 

hospitalized with pneumonia. Rev Assoc 

Med Bras 2003; 49: 191-5. 

10. Krause MF, von Bismarck P, Oppermann HC, 

Ankerman T. Bronchoscopic surfactant administration 

in pediatric patients with persistent lobar 

atelectasis. Respiration 2008; 75: 100-4. 

11. Toyoshima M, Maeoka Y, Kawahare H, Maegaki 

Y, Ohno K. Pulmonary atelectasis in patients with 

neurological or muscular disease; gravity-related 

lung compression by the heart and intra-abdominal 

organs on persistent supine position. No To 

Hattatsu 2006; 38: 419-24. 

12. Lutterbey G, Wattjes MP, Doerr D, Fischer NJ, 

Gieseke J Jr, Schild HH. Atelectasis in children 

undergoing either propofol infusion or positive 

pressure ventilation anesthesis for magnetic resonance 

imaging. Pediatr Anesth 2007; 17: 121-5. 

13. Blitman NM, Lee HK, Jain VR, Vicencio AG, 

Girshin M, Haramati LB. Pulmonary atelectasis 

in children anesthetized for cardiothoracic MR: 

evaluation of risk factors. J Comput Assist Tomogr 

2007; 31: 789-94. 

14. Wu KH, Lin CF, Huang CJ, Chen CC. Rigid ventilation 

bronchoscopy under general anesthesia 

for treatment of pediatric pulmonary atelectasis 

caused by pneumonia: A review of 33 cases. In 

Surgery 2006; 91: 291-4. 

15. Tumgor G, Celik U, Alabaz D, Cetiner S, Yaman 

A, Yildizdas D, Alhan E. Aetiological agenst, 

interleukin-6, interleukin-8 and CRP concentrations 

in children with communitiy-acquired pneumonia. 

Ann Trop Pediatr 2006; 26:285-91. 

16. Almirall J, Bolibar I, Toran P, Pera G, Boquet X, 

Balanzo X, Sauca G. Contribution of C-reactive 

protein to the diagnosis and assesment of severity 

of community-acquired pneumonia. Chest 2004; 

125:1335-42. 

17. Lagerstrom F, Engfeldt P, Holmberg H. C-reactive 

protein in diagnosis of comunity-acquired 

pneumonia in patient in primary care. Scand Infect 

Dis 2006; 38:964-9. 

18. Lala SG, Madhi SA, Pettifor JM. The discriminative 

value of C-reactive protein levels in distinguishing 

betwen community-acquired bacteriaemic 

and respiratory virus-associated lower 

respiratory tract infections in HIV-1-infected 

and uninfected children. Ann Trop Pediatr 2002; 

22:271-9. 

19. Bircan A, Kaya O, Gokirmak M, Ozturk O, Sahin 

U, Akkaya A. C-reactive protein, leukocyte count 

and ESR in the assesment of severity of community-acquuired 

pneumonia. Tuberk Toraks 2006; 

54:22-9. 

20. Schechter MS. Airway clearence applications in 

infants and children. Respir Care 2007; 52: 1382- 

90. 

21. Bar-Zohar D, Sivan Y. The yield of flexible 

fiberoptic bronchoscopy in pediatric intensive 

care patients. Chest 2004; 126: 1353-9. 

22. Choudhury SR, Chadha R, Mishra A, Kumar V, 

Singh V, Dubey NK. Lung resections in children 

for congenital and acquired lesions. Pediatr Surg 

2007; 23: 851-9.

Lung atelectasis and lower respiratory tract infections in chil- 

dren in the intensive care unit 

Nada Mladina¹, Devleta Hadžić¹, Amela Selimović² 

¹Pediatrics Clinic, ²Gynecology and Obstetrition Clinic; University and Clinical Center Tuzla, Bosnia and Herzegovina 

ABSTRACT 

Aim To determine etiologic, clinical and radiological findings of lung atelectasis in children undergoing 

intensive treatment in the Department of Intensive Care Unit at the Pediatric Clinic Tuzla in one-year 

period. 

Methods We analyzed a group of 31 children with lower respiratory tract infections and pulmonary 

atelectasis. Their average age was 3,6 ± 3,9 years. We analyzed etiologic, clinical and radiological findings 

of pulmonary atelectasis among children with lower respiratory tract infections. 

Results In one year period we treated 332 patients due to lower respiratory tract infections, bronchitis 

and pneumonia, 208 boys (62, 7%) and 124 girls (37, 3%). In 224 (67,5%) patients radiologic findings 

showed pneumonia, while in 31(9,3%) of patients radiological findings showed pneumonia and pulmonary 

atelectasis, as well. The most frequent was the right-sided atelectasis (20 or 64,5%), while in 10 or 

32,3% left sided atelectasis was noticed. In only one patient (3,2%) bilateral atelectasis was found. Generally 

etiologic base was the infection of lower respiratory tract (30 or 96, 8%). It was only one patient 

with mediastinal expansive process. Clinical signs, gas analyses and plus oximetries were in correlation 

and showing hypoxemic type of respiratory insufficiency. The most frequent cause of lung atelectasis 

was mucus stasis. All 31 patients demanded oxygen therapy and monitoring of vital parameters at least 

for 24 hours, while in 12 or 38,7% of them, monitoring of vital parameters was needed longer than 24 

hours. Average duration of intensive treatment was 4, 3± 2, 7 days (1-15 days). 

Conclusion Pulmonary atelectasis are not rare in children with lower respiratory tract infections in 

Intensive Care Unit. They are an additional risk factor for serious disturbances of pulmonary ventilation, 

especially in infancy. 

Key words: pulmonary atelectasis, lower respiratory tract, child 


22 July 2008.; 


25 October 2008; 

Accepted: 

08 November 2008. 


187

188 


Evaluacija dijagnostičke vrijednosti interleukina-6 i C-reaktivnog 

proteina iz krvi pupčanika u prepoznavanju rane infekcije terminske 

novorođenčadi male porođajne mase 

Almira Ćosićkić 1 , Fahrija Skokić 2 , Selmira Brkić 3 

1 2 3 Klinika za dječije bolesti, Ginekološko-akušerska klinika, Odjel za neonatologiju, Univerzitetski klinički centar Tuzla; Zavod za patološku 

fiziologiju, Medicinski fakultet Univerziteta u Tuzli; Tuzla, Bosna i Hercegovina 


Almira Ćosićkić, 

Klinika za dječije bolesti, 

Univerzitetski klinički centar Tuzla, 

Trnovac bb, 75000 Tuzla, 


Phone/fax.: ++387 35 303-700; 

E-mail: almira_cosickic@yahoo.com 


12. august 2008.; 


16. septembar 2008.; 

Prihvaćeno: 

07. novembar 2008. 

Med Glas 2009; 6(2): 188-196 

SAŽETAK 

Cilj Evaluirati dijagnostičku vrijednost interleukina-6 (IL-6) 

i C-reaktivnog proteina (CRP) iz krvi pupčanika u prepoznavanju 

rane novorođenačke infekcije (RNI) prema kliničkoj slici, 

hematološkim parametrima i mikrobiološkim nalazima. 

Metode Provedeno je retrospektivno-prospektivno istraživanje u 

Klinici za ginekologiju i akušerstvo u Tuzli. Uključujući kriteriji 

bili su porođajna masa < 2.500 grama, dob od 37. do 42. gestacijske 

nedjelje, novorođenčad oba spola, iz jednoplodne trudnoće 

i bez vidljivih anomalija na rođenju. Isključujući kriteriji bili 

su porođajna masa > 2.500 grama, gestacijska dob < 37 nedjelja, 

višeplodna trudnoća, novorođenčad sa kongenitalnim anomalijama. 

Kriterije je zadovoljilo 120 novorođenčadi, a formirane su 

dvije grupe: ispitivana, novorođenčad s RNI (n = 28) i kontrolna 

grupa, novorođenčad bez RNI (n = 92). Analizirane su vrijednosti 

IL-6 i CRP-a iz krvi pupčanika, klinička slika, hematološki parametri 

i mikrobiološki nalazi. 

Rezultati Vrijednosti IL-6 < 10 pg/mL smatrane su normalnim za 

novorođenačku dob. Medijan vrijednosti IL-6 u ispitivanoj grupi 

bio je 49 pg/mL, a u kontrolnoj 9.7 pg/mL, uz značajnu razliku 

među grupama (p < 0.0001). Senzitivnost testa IL-6 bila je 82% i 

specifičnost 89%. Vrijednosti CRP-a < 5.0 mg/L smatrane su normalnim 

za novorođenačku dob. Medijan CRP-a u ispitivanoj grupi 

iznosio je 3.5 mg/l, a u kontrolnoj 2.8 mg/L bez značajne razlike 

među grupama (p = 0.997). Senzitivnost testa CRP-a bila je 25% 

i specifičnost 86%. Niska je bila i senzitivnost kombinacije oba 

testa IL-6 i CRP-a 21% prema dijagnostičkim parametrima RNI, 

ali je specifičnost bila značajna (87%). 

Zaključak Dijagnostička vrijednost IL-6 iz krvi pupčanika u 

prepoznavanju RNI je značajna, dok je vrijednost CRP-a iz krvi 

pupčanika ograničena. 

Ključne riječi: interleukin-6, C-reaktivni protein, rana novorođenačka 

infekcija.

UVOD 

Rana novorođenačka infekcija (RNI) 

značajan je uzrok morbiditeta i mortaliteta 

novorođenčadi, a njeno prepoznavanje često se 

temelji na procjeni znakova i simptoma koji su 

nespecifični i mogu podsjećati na mnoga druga 

neinfektivna stanja, koja su zapravo odraz 

ekstrauterine adaptacije novorođenčeta (1). 

Novorođenčad male porođajne mase (MPM) predstavljaju 

rizičnu grupu jer imaju visoku perinatalnu 

smrtnost, češće komplikacije u novorođenačkom 

periodu, veću učestalost kongenitalnih anomalija 

i sklonija su infekcijama (2). Imunološki sistem 

novorođenčeta razvija se postepeno, te osim što 

neki njegovi dijelovi nisu potpuno razvijeni, oni 

su i bez iskustva jer u zaštićenoj intrauterinoj 

sredini nisu morali reagirati na strane antigene. 

Komponente nespecifične, a posebno specifične 

imunosti, ispoljavaju funkcijske i kvantitativne 

nedostatke što rezultira neadekvatnim upalnim 

odgovorom i povećanom sklonosti novorođenčadi 

ka infekciji, naročito novorođenčadi MPM (3). 

Interleukin-6 (IL-6), citokin prisutan u najranijoj 

fazi upale, značajan je medijator upalnog odgovora, 

stimulira stanice jetre na stvaranje reaktanata 

akutne faze upale, a među njima i C reaktivnog 

proteina (CRP) (4). Određivanje citokina iz krvi 

pupčanika može predstavljati put kojim se prepoznaju 

novorođenčad ugrožena infekcijom (5). 

Procjena pouzdanosti povišenih vrijednosti 

reaktanata akutne faze upale u novorođenčadi 

za otkrivanje infekcije sve je potrebnija u svakodnevnoj 

kliničkoj praksi. Uz hipotezu da bi 

se određivanje citokina iz krvi pupčanika moglo 

koristiti za pravovremeno prepoznavanje novorođenčadi 

sa RNI, cilj ovoga rada jeste da se 

evaluira dijagnostička vrijednost IL-6 i CRP-a iz 

krvi pupčanika u pravovremenom prepoznavanju 

RNI u odnosu na kliničku sliku, hematološke 

parametre i mikrobiološke nalaze. 


Provedeno je retrospektivno-prospektivno 

istraživanjem u Klinici za ginekologiju i aku- 

Ćosićkić et al IL-6 i CRP u ranoj novorođenačkoj infekciji 

šerstvo Univerzitetskog kliničkog centra u Tuzli 

(UKC Tuzla) u vremenskom periodu od marta 

do septembra 2006. godine. Uključujući kriteriji 

bili su porođajna masa novorođenčadi manja od 

2.500 grama, gestacijska dob novorođenčadi od 

37. do 42. gestacijske nedjelje, novorođenčad iz 

jednoplodne trudnoće, oba spola, bez vidljivih 

anomalija na rođenju. Isključujući kriteriji bili su 

porođajna masa novorođenčadi iznad 2.500 grama, 

gestacijska dob novorođenčadi < 37 nedjelja, 

višeplodna trudnoća majke, novorođenčad sa 

kongenitalnim anomalijama. Uslove istraživanja 

zadovoljilo je 120 novorođenčadi od kojih su 

formirane dvije grupe: ispitivana grupa novorođenčadi 

(ispitanici) sa RNI (novorođenčad sa 

pozitivnim dijagnostičkim parametrima: klinička 

slika, hematološki parametri i mikrobiološki nalazi) 

(n = 28) i kontrolna grupa (kontrolni) novorođenčadi 

bez infekcije (n = 92). 

U prvih 48 sati po rođenju praćeni su klinički 

znaci od strane respiratornog i kardiovaskularnog 

sistema, poremećaj regulacije tjelesne temperature 

i patološke promjene u krvnoj slici (6, 7) . 

Zahvaćenost respiratornog sistema bila je 

prisutna ako je postojao bar jedan od slijedećih 

poremećaja: tahipneja > 60 udisaja u minuti, dispneja, 

apneja ili postojanje potrebe za ventilacijom 

novorođenčeta (8). Pozitivni znaci od strane 

kardiovaskularnog sistema uključivali su prisutnost 

jednog ili više slijedećih parametara: srčana 

akcija u mirovanju iznad 160 otkucaja u minuti, 

slab periferni puls, krvni pritisak ispod petog percentila 

za dob, nivo bikarbonata ispod 15 mEq/ 

litar, pH krvi ispod 7.30 i potreba za nadoknadom 

volumena (9). Tjelesna temperatura, mjerena 

rektalno, manja od 36,5°C ili veća od 38,0 °C 

smatrana je patološkom. Hematološki parametri 

obuhvaćali su patološke promjene u krvnoj slici i 

smatrani su pozitivnim kada je bilo prisutno tri i 

više od sedam parametara (ukupan broj leukocita 

< 5.000 ili > 30.000, ukupan broj segmentiranih 

leukocita iznad 5.000, ukupan broj nesegmentiranih 

leukocita veći od 500, odnos nesegmentiranih 

i segmentiranih leukocita veći od 0.2, prisutnost 

toksičnih granulacija, prisutne mlade forme leukocita 

i trombocitopenija) hematološkog skor si- 

189

190 


stema za ranu dijagnozu neonatalne sepse prema 

Rodwellu i suradnicima (10) . 

Analizirane su vrijednosti IL-6 i CRP-a iz 

krvi pupčanika novorođenčadi, te dijagnostički 

parametri za RNI: klinička slika, hematološki 

parametri i mikrobiološki nalazi (kultura krvi, 

urina i likvora). 

Za identifikaciju uzročnika infekcije korišten 

je nalaz kulture krvi, te je za svu novorođenčad, 

uključenu u istraživanje, uzet 1mL krvi iz pupčanika 

u bočice za uzimanje hemokulture (BD 

Bactec PEDS PLUS/F, Dickinson and Company, 

SparksLab Supplies Ltd, Shannon, Ireland). Kultura 

likvora i standardni pregled likvora načinjeni 

su samo za onu novorođenčad koja su imala 

simptome koji su upućivali na meningitis. Urin za 

bakteriološku kulturu, za svu novorođenčad uključenu 

u istraživanje, prikupljen je urinarnim vrećicama 

koje su zamijenjivane svakih 30 minuta do 

prikupljanja uzorka. Uzorci su analizirani u Poliklinici 

za laboratorijsku dijagnostiku, Odjeljenje 

mikrobiologije UKC Tuzla. Izolacija bakterijskog 

uzročnika u značajnom broju (>10 5 ) za određenu 

kulturu smatrana je pozitivnim nalazom. 

Krv iz pupčanika za određivanje vrijednosti 

IL-6 i CRP-a uzeta je neposredno po rođenju, 

standardnom procedurom i analizirana je u Poliklinici 

za laboratorijsku dijagnostiku, Odjeljenje 

imunologije UKC Tuzla. Uzorci krvi za analizu 

IL-6 centrifugirani su brzinom 2.000 okretaja u 

minuti tokom 10 minuta. Nakon centrifugiranja, 

odvojeni serum čuvao se u flakonima na temperaturi 

-80°C, do postupka određivanja na svim uzorcima. 

IL-6 određivan je metodom ELISA (Metertech 

960, Quantikine Human IL-6, R&D systems, 

Metertech Inc, Taipei, Taiwan). Vrijednosti IL-6 

od 0 do 10 pg/mL smatrane su normalnim. 

Uzorci krvi za određivanje CRP-a analizirani 

su u toku 24 sata po uzimanju uzorka pomoću 

nefelometra (BN2, Behring,GmBH, Marburg, 

Germany). Vrijednosti CRP-a od 0 do 5.0 mg/l 

smatrane su normalnim (11). 

Prethodno je dobiven pristanak Etičkog 

komiteta i svake majke da želi sudjelovati u 

navedenom istraživanju. 

U statističkoj obradi podataka za testiranje 

statističkog značaja razlike među uzorcima korišten 

je neparametrijski Mann-Whitneyev test za 

numeričke varijable, χ 2 –test korišten je za uspoređivanje 

frekvencija, te omjer izgleda (OR) sa 

95%-tnim rasponom pouzdanosti (CI). Razlika 

među uzorcima smatrana je značajnom ako je 

vrijednost p iznosila < 0.05. 

Validnosti analiza IL-6 i CRP-a iz krvi 

pupčanika procijenjene su izračunavanjem senzitivnosti, 

specifičnosti, njihovih pozitivnih i negativnih 

prediktivnih vrijednosti, te dijagnostičke 

tačnosti. 

Za obradu podataka korišten je statistički 

program Arcus QuickStat (12). 

REZULTATI 

U periodu od 1. marta 2006. godine do 30. 

septembra 2006. godine u Klinici za ginekologiju 

i akušerstvo u Tuzli od ukupno 2.449 živorođene 

novorođenčadi porođajnu masu manju od 2.500 

grama imalo je 171 (6,98%) novorođenče. Iz 

istraživanja je isključeno 51 novorođenče male 

porođajne mase (MPM), od kojih je 41 rođeno 

prije 37. gestacijske nedjelje, 9 novorođenčadi je 

bilo iz višeplodne trudnoće, a jedno je rođeno s 

vidljivim anomalijama. 

Porođajna masa novorođenčadi kretala se u 

rasponu od 2.120 grama do 2.480 grama (medijan 

2.230 grama). Gestacijska dob novorođenčadi 

bila je u rasponu od 37. do 42. (medijan 38) 

gestacijske nedjelje. Rođena su u relativno dobroj 

kondiciji s Apgar-skorom u prvoj minuti u 

rasponu vrijednosti od 6 – 8 (medijan 6.78), te su 

bila češće ženskog spola. Kliničke karakteristike 

novorođenčadi prikazane su u Tablici 1. 

Pozitivne mikrobiološke nalaze imalo je 

38/120 (31,7%) terminske novorođenčadi MPM, 

od toga pozitivnu kulturu krvi imalo je 22/38 

(57,9%) novorođenčadi (u najvećem broju izolovan 

je Streptococcus β-haemoliticus, 11/22), 

pozitivna urinokultura bila je kod 12/38 (31,6%) 

novorođenčadi (u najvećem broju izolovana je E. 

coli, 7/12) i kod 4/38 novorođenčadi bila je pozi-

Tablica 1. Kliničke karakteristike ispitivane djece 

Kliničke karakteristike novorođenčadi (N = 120) 

Gestacijska dob (nedjelje), raspon 

(medijan) 

37-42 (38) 

Porođajna masa (g) raspon (medijan) 2.120- 2.480 (2.230) 

Porođajna dužina (cm) raspon (medijan) 48.5-51.5 (49.8) 

Apgar-skor 1. minut, raspon (medijan) 6-8 (6.78) 

Apgar-skor 5. minut, raspon (medijan) 7-9 (8.2) 

Perinatalna asfiksija (n; %) 4 (3,3%) 

Muški spol (n; %) 38 (31,7%) 

tivna kultura likvora, gdje je Staphylococcus aureus 

izolovan u tri slučaja, dok je iz jednog uzorka 

izolovan Streptococcus β haemoliticus. Kliničku 

sliku za RNI imalo je 36/120 (30%) terminske 

novorođenčadi MPM, a najčešći su bili: odbijanje 

i/ili loše podnošenje hrane (82%), povišena 

tjelesna temperatura (60%), letargija (58%), 

povraćanje (44%), hiperbilirubinemija (42%). 

Pozitivne hematološke parametre za RNI imalo je 

32/120 (26,7%) terminske novorođenčadi MPM, a 

najčešći su bili: odnos nesegmentiranih i segmentiranih 

leukocita > 0.2 (68%), leukocitoza (66%), 

trombocitopenija (52%) i leukopenija (32%). 

Pozitivne sve dijagnostičke parametre 

(klinička slika, hematološki parametri i 

mikrobiološki nalazi) za RNI imalo je 28/120 

(23,3%) terminske novorođenčadi MPM koja su 

i činila ispitivanu grupu. 

Povišene vrijednosti IL-6 zabilježene su 

kod 33/120 (27,5%) terminske novorođenčadi 

MPM. Vrijednosti IL-6 uzetog na rođenju iz 

krvi pučanika u ispitivanoj grupi kretale su se u 

rasponu od 9.5 pg/mL do 60 pg/mL, uz medijan 

od 49 pg/mL. U kontrolnoj grupi vrijednosti IL-6 

uzetog iz krvi pupčanika kretale su se u rasponu 

3.1 pg/mL do 52 pg/mL, uz medijan 9.7 pg/mL. 

Mann-Whitneyevim testom uočena je statistički 

značajna razlika između medijana vrijednosti IL-6 

u ispitivanoj i kontrolnoj grupi (P < 0.0001). 

Povišene vrijednosti CRP-a imalo je 20/120 

(16,7%) terminske novorođenčadi MPM. Vrijednosti 

CRP-a uzete iz krvi pupčanika, u ispitivanoj 

grupi kretale su se u rasponu 0.1 mg/L do 12.5 

mg/L, uz medijan 3.5 mg/L, dok su u kontrolnoj 

grupi bile u rasponu 0.1 mg/L do 9.4 mg/L, 

a medijan je iznosio 2.8 mg/L. Ustanovljena je 

statistički značajna razlika između medijana vri- 


Tablica 2. Brojčani odnos vrijednosti interleukina-6 i 

dijagnostičkih parametara za ranu novorođenačku infekciju 

u terminske novorođenčadi, omjer izgleda pozitivnog i negativnog 

nalaza 

IL-6 (pg/ml) 

> 10 

≤ 10 

Dijagnostički parametri za RNI* 

Pozitivan Negativan 

23 

5 

10 

82 

Ukupno 

33 

87 

Ukupno 28 92 120 

* rana novorođenačka infekcija; χ2 = 54.69; P < 0.001; OR = 37.72 

(95%CI: 11.72 - 121.398) 

jednosti CRP-a u ispitivanoj i kontrolnoj grupi (P 

= 0.997). 

Vrijednosti IL-6 iznad 10 pg/mL i pozitivne 

dijagnostičke parametre za RNI (klinička slika, 

hematološki parametri i mikrobiološki nalazi) imalo 

je 23/120 (19,1%) terminske novorođenčadi 

MPM (Tablica 2). Uočena je statistički značajna 

povezanost povišenih vrijednosti IL-6 i pozitivnih 

dijagnostičkih parametara za RNI (χ 2 = 54.69, P 

192 


Tablica 3. Brojčani odnos vrijednosti C-reaktivnog proteina i 

dijagnostičkih parametara za ranu novorođenačku infekciju 

u terminske novorođenčadi male porođajne mase, omjer 

izgleda pozitivnog i negativnog nalaza 

CRP (mg/l) 

> 5 

≤ 5 

Dijagnostički parametri za RNI* 


7 

21 

13 

79 

Ukupno 

20 

100 

Ukupno/Total 28 92 120 

*rana novorođenačka infekcija; χ2 = 1.82; P =0.176; OR = 2.025 

(95%CI: 0.717-5.715) 

nost i dijagnostička tačnost vrijednosti IL-6, dok je 

negativna prediktivna vrijednost bila niska. 

Povišene vrijednosti CRP-a i pozitivne 

dijagnostičke parametre RNI imalo je 7/120 

(5,8%) terminske novorođenčadi MPM, dok 

je 21/120 (17,5%) novorođenčadi sa prisutnim 

dijagnostičkim parametrima za RNI imalo normalne 

vrijednosti CRP-a za novorođenačku dob 

(Tablica 3). Nije uočena statistički značajna povezanost 

povišene vrijednosti CRP-a s dijagnostičkim 

parametrima RNI u terminske novorođenčadi 

MPM (p = 0.17). Vjerovatnost pojave visokih 

vrijednosti CRP-a bila je samo 2,02 puta veća 

(95%CI: 0.717-5.715) kod novorođenčadi s pozitivnim 

dijagnostičkim parametrima, nego kod 

novorođenčadi s negativnim. Vjerovatnost pojave 

povišenog CRP-a bila je samo 0,71 puta veća ako 

su i dijagnostički parametri za RNI bili pozitivni. 

Validnost povišene vrijednosti CRP-a u prepoznavanju 

RNI praćena putem senzitivnosti, 

specifičnosti, pozitivne i negativne prediktivne 

vrijednosti, te dijagnostičke tačnosti prikazana je 

na Slici 2. Uočena je niska senzitivnost i negativna 

prediktivna vrijednost povišene vrijednosti 

* PPV, pozitivna prediktivna vrijednost; ** NPV, negativna prediktivna 

vrijednost 

Slika 2. Validnost testa C-reaktivnog proteina u odnosu 

na dijagnostičke parametre rane novorođenačke infekcije 

terminske novorođenčadi male porođajne mase* 

Tablica 4. Brojčani odnos vrijednosti interleukina-6, 

C-reaktivnog proteina i dijagnostičkih parametara za ranu 

novorođenačku infekciju u terminske novorođenčadi male 

porođajne mase, omjer izgleda pozitivnog i negativnog nalaza 

IL-6 (granična vrijednost 

10 pg/ml) 

CRP (granična 

vrijednost 5 mg/l) 

> 

< 

Dijagnostički parametri 

RNI* 


6 

22 

12 

80 

Ukupno 

18 

102 

Ukupno/ Total 28 92 120 

* rana novorođenačka infekcija; χ2 = 1.183, P = 0.276; OR = 1.818 

(95%CI: 0.612-5.398) 

CRP-a u odnosu na analizirane dijagnostičke parametre, 

ali je specifičnost i dijagnostička tačnost 

bila značajna. 

Povišene vrijednosti IL-6 i CRP-a, kao i pozitivne 

dijagnostičke parametre RNI, imalo je 6/120 

(5%) terminske novorođenčadi MPM, dok je 

22/120 (18,3%) terminske novorođenčadi MPM s 

pozitivnim dijagnostičkim parametrima imalo IL-6 

i CRP normalnih vrijednosti za novorođenačku 

dob (Tablica 4). Nije bilo statistički značajne 

povezanosti povišenih vrijednosti IL-6, CRP-a 

sa analiziranim dijagnostičkim parametrima (p = 

0.276). Vjerovatnost pojave visokih vrijednosti 

IL-6 i CRP-a zajedno bila je samo 1,81 puta veća 

(95%CI: 0.612-5.398) kod novorođenčadi s pozitivnim 

dijagnostičkim parametrima za RNI nego 

kod novorođenčadi s negativnim. 

Validnost povišene vrijednosti IL-6, uz 

povišene vrijednosti CRP-a u prepoznavanju RNI, 

a prema analiziranim dijagnostičkim parametrima, 

praćena putem senzitivnosti, specifičnosti, 

pozitivne i negativne prediktivne vrijednosti, te 

dijagnostičke tačnosti, prikazana je na Slici 3. 

* PPV, pozitivna prediktivna vrijednost; ** NPV, negativna prediktivna 

vrijednost 

Slika 3. Validnost testova interleukina-6 i C-reaktivnog proteina 

u odnosu na dijagnostičke parametre rane novorođenačke 

infekcije terminske novorođenčadi male porođajne mase*

Uočena je niska senzitivnost, ali je specifičnost i 

dijagnostička tačnost bila značajna. 

DISKUSIJA 

U ovom istraživanju istražena je dijagnostička 

vrijednost interleukina-6 (IL-6) i C-reaktivnog 

proteina (CRP-a) iz krvi pupčanika prema dijagnostičkim 

parametrima za ranu novorođenačku 

infekciju (RNI) (klinička slika, hematološki parametri 

i mikrobiološki nalazi) s namjerom da 

se utvrdi njihova pouzdanost u pravovremenom 

prepoznavanju RNI-a u terminske novorođenčadi 

male porođajne mase (MPM). 

U strukturi morbiditeta i mortaliteta 

novorođenčadi, RNI ima značajan udio. Do 

teških oštećenja ili smrti, obično dolazi u prva 24 

sata po rođenju, dok je klinička slika još nejasna, 

laboratorijski nalazi nespecifični, a mikrobiološki 

nalazi tek uzeti (13). Pristupanje inicijalnom antibiotskom 

tretmanu zasniva se upravo na kliničkim 

znacima bolesti, hematološkim parametrima i 

podacima o epidemiološkim faktorima vezanim 

za RNI. Ove su procjene subjektivne, tako da 

terapija često bude primijenjena nepotrebno. 

Od trideset novorođenčadi kod kojih se terapija 

započne na osnovu ovakvih procjena, potreba za 

antibiotskom terapijom dokaže se samo u jednog 

novorođenčeta (14, 15). 

U našem istraživanju uočili smo značajnu 

povezanost vrijednosti IL-6 iz krvi pupčanika s 

pozitivnim dijagnostičkim parametrima za RNI, 

kao i značajno visoku senzitivnost i specifičnost 

IL-6 iz krvi pupčanika. Visoka pozitivna prediktivna 

vrijednost, te značajna povezanost vrijednosti 

IL-6 i pozitivnih dijagnostičkih parametara 

za RNI, potvrđuju i u našem istraživanju pouzdanost 

ovog dijagnostičkog parametra u prepoznavanju 

RNI. Naši rezultati o validnosti testa IL-6 

iz krvi pupčanika donekle su slični rezultatima 

drugih istraživanja. Yoon i suradnici (16) dokazali 

su značajnu povezanost povišenih vrijednosti 

IL-6 iz krvi pupčanika s nastankom RNI. Reyes 

i suradnici (17) istakli su senzitivnost IL-6 za 

prepoznavanje RNI od 80%. Rezultati nekoliko 

studija potvrdili su da je IL-6 iz krvi pupčanika 


senzitivni marker za dijagnozu novorođenačke 

infekcije koja nastaje u prva 72 sata života, uz 

senzitivnost 87-100% i negativnu prediktivnu 

vrijednost 93-100% (18-20). Drugi istraživači 

ističu pouzdanost IL-6 i u prepoznavanju kasne 

novorođenačke infekcije, uz senzitivnost 89% i 

negativnu prediktivnu vrijednost 91%, te kako je 

značajno senzitivniji od drugih markera, a među 

njiima i CRP-a (21) . Hadžijaki i suradnici (22) 

analizirali su vrijednosti IL-6 majčine krvi, iz 

krvi pupčanika i periferne krvi novorođenčadi. 

Došli su do rezultata da su vrijednosti IL-6 iz 

krvi pupčanika značajno veće u novorođenčadi 

s infekcijom, uz senzitivnost 95%, specifičnost 

100%, pozitivnu prediktivnu vrijednost 100% 

i negativnu prediktivnu vrijednost 97,4%, te su 

zaključili da je IL-6 iz krvi pupčanika jedan od 

najsenzitivnijih markera za prepoznavanje RNI. 

S druge pak strane, Janota i suradnici (23) su 

istakli da vrijednosti IL-6 iz krvi pupčanika ili 

iz krvi novorođenčeta, uzete u prva dva sata života, 

nema dovoljnu senzitivnost, ni specifičnost 

za prepoznavanje RNI. Dooy i suradnici (24) 

analizirali su povezanost stvaranja inflamatornih 

medijatora i perinatalne kolonizacije respiratornog 

trakta. Njihovi rezultati govore o tome da su 

proinflamatorni citokini, među kojima je i IL-6, 

bili značajno povećani u novorođenčadi koja je 

bila inficirana gram-negativnim patogenima koji 

su izolirani mikrobiološkim nalazima. 

U našem istraživanju, povišene vrijednosti 

CRP-a i pozitivne dijagnostičke parametre za 

RNI imalo je 5,8% terminske novorođenčadi 

MPM i nismo pronašli ovisnost povišene vrijednosti 

CRP-a iz krvi pupčanika i dijagnostičkih 

parametara za RNI. Procjenom validnosti povišene 

vrijednosti CRP-a iz krvi pupčanika u prepoznavanju 

RNI, našli smo nisku senzitivnost, 

ali značajnu specifičnost i dijagnostičku tačnost. 

Ovako značajna specifičnost testa CRP-a potvrda 

je da negativan nalaz CRP-a sa značajnom sigurnošću 

znači i odsutnost infekcije. 

Mali broj novorođenčadi ispitivane grupe 

s povišenim CRP-om tumačimo njegovom 

biološkom ulogom u organizmu i dinamikom 

njegove sinteze. Odgađanje njegovog porasta 

193

194 


za nekoliko sati počiva na kaskadi zbivanja koja 

dovode do porasta razine CRP-a, uključujući aktivaciju 

neutrofila, poticaja od strane IL-6 i same 

hepatičke sinteze CRP-a (25). Benitz i suradnici 

(25) u svojoj studiji ukazali su kako je serijsko 

mjerenje CRP-a iz krvi pupčanika, a potom 12- 

24 sata nakon rođenja, značajno za otkrivanje 

novorođenčadi s infekcijom. Nameće se zaključak 

da je senzitivnost testa CRP-a iz krvi pupčanika, 

u našem istraživanju, očekivano snižena, s obzirom 

na potrebu praćenja vrijednosti CRP-a u 

određenim vremenskim intervalima (12 do 24 

sata). Arshad i suradnici (26) ustanovili su da povišen 

CRP, 12 do 24 sata nakon pojave znakova 

infekcije, ima pozitivnu prediktivnu vrijednost od 

samo 7-43%, ali negativnu prediktivnu vrijednost 

od 97-99,5%, te se CRP može smatrati vrlo korisnim 

u procjeni odsutnosti infekcije. Isti autori 

ističu kako je senzitivnost CRP-a iznosila 86,7% 

za slučajeve RNI s pozitivnom hemokulturom 

i 80,6% za slučajeve RNI s negativnom hemokulturom. 

Zeeshan i suradnici (27) izvijestili su 

o senzitivnosti, specifičnosti, pozitivnoj i negativnoj 

prediktivnoj vrijednosti CRP-a od 85,7%, 

95%, 82,7% i 95,9% u grupi novorođenčadi s 

pozitivnim nalazom hemokulture. 

Jedan od razloga širokog raspona senzitivnosti 

CRP-a, koji se kreće od 47-100% i 

specifičnosti od 6-97% u detekciji RNI, donekle 

je i u činjenici o još uvijek neusuglašenom stavu u 

literaturi o dopuštenoj gornjoj vrijednosti CRP-a 

u novorođenačkom periodu. Mogući razlog diskrepance 

u senzitivnosti CRP-a u različitim studijama 

može biti i različitost dijagnostičkih kriterija, 

ali i različitih metoda kojima se određuje 

vrijednost CRP-a (28). 

LITERATURA 

1. 

2. 

Stoll BJ. Infections of the neonatal infant. U: 

Behrman RE, Kliegman RM, Jenson HB ur. Nelson 

textbook of pediatrics. 17. izd. Philadelphia: 

WB Saunders, 2004:623-40. 

Levene M, Tudehope D, Thearle J. Neonatal 

transport and organition of perinatal services.U: 

Levene M, Tudehope D, Thearle M, ur. Essentials 

of neonatal medicine. London: Blackwell Science 

Ltd, 2000: 283-89. 

U našem istraživanju nismo uočili značajnu 

povezanost povišene vrijednosti oba testa, i IL-6 

i CRP-a, sa pozitivnim dijagnostičkim parametrima 

RNI. Evaluacijom validnosti kombinacije 

oba testa, i IL-6 i CRP-a, našli smo nisku senzitivnost, 

ali je specifičnost bila značajna. Naši 

rezultati o validnosti kombinacije testova IL-6 

i CRP-a nešto se razlikuju od rezultata drugih 

istraživanja. Khassawnwh i suradnici (29) 

izvještavaju o značajnoj prednosti CRP-a prema 

vrijednostima IL-6 i IgM u prepoznavanju infekcije 

novorođenčadi sa senzitivnošću CRP-a 95% 

i negativnom prediktivnom vrijednosti 98%. 

Zaključuju da su CRP, IL-6 i IgM u kombinaciji 

veoma korisni za ranu dijagnozu gram-negativne 

neonatalne sepse. Døllner i suradnici (30) ističu 

pouzdanost kombinovanog testa CRP-a i IL-6 u 

prepoznavanju novorođenčadi s infekcijom i vjerovatnom 

infekcijom i njihove senzitivnosti 85% 

i specifičnosti 62%. 

Dijagnostička vrijednost IL-6 iz krvi pupčanika 

u prepoznavanju RNI značajna je zbog visoke 

senzitivnosti, specifičnosti i prediktivne pozitivne 

vrijednosti, dok je dijagnostička vrijednost CRP-a 

iz krvi pupčanika niske senzitivnosti, ali visoke 

specifičnosti, te može poslužiti kao brza i danas 

lako dostupna pretraga kojom se mogu, s velikom 

sigurnošću, probrati novorođenčad bez infekcije. 



ne postoji. 

3. 

4. 

Prober CG. Clinical approach to the infected neonate. 

U: Long SS, Pickerin LK, Prober CG ur. 

Principles and practice of pediatric Infectious diseases. 

New York: Churchill Livingstone, 1997: 

603-09. 

Naccasha N, Hinson R, Montag A, Ismail M, 

Bentz L, Mittendorf R. Association between funisitis 

and elevated interleukin-6 and C-reactive 

protein in cord blood. Obstet Gynecol 2001; 97: 

220-4.

5. Heep A, Behrendt D, Nitsch P, Fimmers B, Bartmann 

P, Dembinski J. Increased serum levels 

of interleukin 6 are associated with severe intraventricular 

haemorrhage in extremely premature 

infants. Dis Child Fetal Neonatal Ed 2003; 

88:501-4. 

6. Bromberger P, Lawrence JM, Braun D, Saunders 

B, Contreras R, Petitti DB. The Influence of intrapartum 

antibiotics on the clinical spectrum of 

early –onset group B streptococcal infection in 

term infants. J Pediatr 2000; 106:244-50. 

7. Saez-Llorens X, McCracken GH. Sepsis syndrome 

and septic shock In pediatrics: current concepts 

of terminology, patophysology and management. 

J Pediatr 1993; 123: 497-508. 

8. D ′Harlingue AE, Durand DJ. Recognition, stabilization 

and transport of the high risk newborn. 

U : Klaus MH, Fanaroff AA, ur. Care of the high 

risk neonate. 4.izd. Philadelphia: WB Saunders 

Co, 1993; 72-8. 

9. Graves GR, Rhodes PG. Tachycardia as a sign 

of early onset neonatal sepsis. Pediatr Infect Dis 

1984; 3:404-6. 

10. Rodwell RL, Leslie AL, Tudhope DL. Early diagnosis 

of neonatal sepsis using a haematologic 

scoring system. J Pediatr 1993; 12: 761-7. 

11. Mathers NJ, Pohlandt F. Diagnostic audit of C- 

reactive protein in neonatal infekctions. Eur J Pediatr. 

1987; 146:147-51. 

12. Buchan IE. Arcus QuickStat Biomedical version 

1.izd. Cambridge: Adisson Wesley Longman Ltd; 

1997. 

13. Hengst JM. The role of C- reactive protein in the 

evaluation and management of infants with suspected 

sepsis. Adv Neonatal Care 2003; 3:3-13. 

14. Hammerschlag MR, Klein JO, Herschel M, Chen 

FC, Fermin R. Patterns of use of antibiotics in 

two newborn nurseries. N Engl J Med 1997; 

296:1268-9. 

15. Philip AG, Hewitt JR.Early diagnosis of neonatal 

sepsis. Pediatrics 1980; 65:1036-41. 

16. Yoon BH, Roberto RP, Shin J. The relationship 

among inflammatory lesions of the umbilical 

cord (funisitis), umbilical cord plasma interleukin 

6 concentration, amniotic fluid infection, and 

neonatal sepsis. Am J Obstet & Gynecol 2000; 

183:1124-9. 

17. Reyes SC, Garcia-Munoz F, Reyes D, Gonzalez 

G, Dominguez C, Domenech E. Role of cytokines 

(interleukin-1 beta, 6, 8, tumor necrosis factor– 

alpha and soluble receptor of interleukin-2) and 

C- reactive protein in the diagnosis of neonatal 

sepsis. Acta Paediatr 2003; 92:221-7. 

18. Messer J, Eyer D, Donato L. Evaluation of interleukin-6 

and soluble receptors of tumor necrosis 

factor for early diagnosis of neonatal infection. J 

Pediatr 1996; 129:574–80. 


19. Brener R, Niemeyer CM, Leititis JU. Plasma levels 

and gene expression of granulocyte colonystimulating 

factor, tumor necrosis factor-alpha, 

interleukin (IL)-1-beta and soluble intercellular 

adhesion molecule-1 in neonatal early onset sepsis. 

Pediatr Res 1998; 44: 469–77. 

20. Sulian JC, Vintzileos AM, Lai YL. Maternal chorioamnionitis 

and umbilical vein interleukin-6 levels 

for identifying early neonatal sepsis. J Matern 

Fetal Med 1999; 8:88–94. 

21. Ng PC. Diagnostic markers of infection in neonates. 

Arch Dis Child Fetal Neonatal Ed 2004; 89:229. 

Hatzidaki E, Gourgiotis D, Manoura A, Korakaki 

E, Bossios A, Galanakis E. Interleukin- 6 in preterm 

premature rupture of membranes as an indicator 

of neonatal outcome. Am J Perinatol 2001; 

18:387-91. 

22. Janota J, Stranák Z, Bĕlohlávková S, Jirásek JE. 

Chorioamnionitis and early-onset neonatal sepsis 

do not significantly affect levels of interleukin-6 

in very low birth weight infants. Sb Lek 2001; 

102: 411-8. 

23. Dooy JD, Ieven M, Stevens W. Endotracheal colonization 

at birth is associated with a pathogendependent 

aro-and antiinflammatory cytokine 

response in ventilated preterm infants: a prospective 

cohort study. Pediatr Res 2004; 54:547-52. 

24. Benitz WE, Gould JB, Druzin ML. Preventing 

early onset group B streptococcal sepsis, strategy 

development using decision analysis. Pediatrics 

1999; 103:76. 

25. Arshad A, Asghar I, Tariq MA. Role of serum C- 

reactive protein in the rapid diagnosis of neonatal 

sepsis. Pak Armed Forces Med J 2003; 53:178- 

82. 

26. Zeeshan A, Ghafoor T, Waqar T, Ali S, Aziz S, 

Mahmud S. Diagnostic value ff C-reactive protein 

and haematological parameters in neonatal 

sespsis. JCPSP 2005; 15:152-6. 

27. Chiesa C, Panero A, OsbornJF, Simonetti AF, 

Pacifico L. Diagnosis of neonatal sepsis: a clinical 

and laboratory challenge. Clin Chem 2004; 

50:279-87. 

28. Khassawneh M, Hayajneh WA, Kofahi H, Khader 

Y, Amarin Z, Daoud A. Diagnostic markers for 

neonatal sepsis: comparing C-reactive protein, 

interleukin-6 and immunoglobulin M. Scand J 

Immunol 2007; 65:171-5. 

29. Døllner H, Vatten L, Austgulen R. Early diagnostic 

markers for neonatal sepsis: comparing 

C-reactive protein, interleukin-6, soluble tumour 

necrosis factor receptors and soluble adhesion 

molecules. J Clin Epidemiol 2001; 54:1251-7. 

195

196 


Diagnostic value of Interleukin 6 and C-reactive protein from 

umbilical cord blood in recognition of early infection in full-term 

newborns with low birth weight 

Almira Ćosićkić 1 , Fahrija Skokić 2 , Selmira Brkić 3 

1 Clinic for children’s diseases, 2 Clinic for gynecology and obstetrics, Department for neonates; University Clinical Center in Tuzla, 3 

Depatment of Pathophysiology; Medical Faculty inTuzla, 

ABSTRACT 

Aim Diagnostic value evaluation of Interleukin-6 (IL-6) and C-reactive protein (CRP) from the umbilical 

cord blood in diagnosis of early newborn infection (ENI) on the basis of clinical picture, hematological 

parameters and microbiological tests. 

Methods A retrospective-prospective study conducted in the Department of Gynecology and Obstetrics. 

One hundred and twenty newborns were included in the study. Inclusion criteria were: newborns 

with birth weight less than 2500 grams, gestational age from 37 to 42 weeks, both genders, no visible 

anomalies at birth, from a single pregnancy. Newborns were divided into two groups: the examined 

group, newborns with ENI (n=28), and second, control group of newborns without ENI (n=92). IL-6 

and CRP were determined from the umbilical cord blood and clinical picture, hematological parameters 

and microbiological test results. 

Results IL-6 values of from 0 to 10 pg/ml were considered normal. Median IL-6 value of in the first 

group was 49 pg/ml and in the second group 9,7 pg/ml with significant difference between these two 

groups (P


Alterations in body weight and biochemistry in patient treated 

with different psychotropic drugs in a clinic in Istanbul 

Aliye Ozenoglu 1 , Serdal Ugurlu 2 , Huriye Balci 3 , Gunay Can 4 , Funda Elmacıoglu 1 , Yeltekin Demirel 5 , Engin 

Eker 6 

1 2 Ondokuz Mayis University, Samsun Health School, Samsun; Division of Rheumatology, Department of Medicine, Fatih sultan Mehmet 

Education and Research Hospital, Istanbul; 3Central Laboratory, Cerrahpasa Medical Faculty, University of Istanbul; 4Department of Public 

Health, Cerrahpasa Medical Faculty, University of Istanbul,Department of Family Medicine, Medical faculty, University of Cumhuriyet, 

Sivas; 6Cerrahpasa Medical Faculty, University of Istanbul, Istanbul; Turkey. 


Aliye Özenoğlu, 

Ondokuz Mayis University, Samsun 

Health School 

Samsun, Turkey 

Phone: +90 362 231 77 20 

Fax: +90 362 231 77 21 

E-mail: aozenoglu@omu.edu.tr; 


17 November 2008; 


30 April 2009; 

Accepted: 

18 May 2009. 

Med Glas 2009; 6(2): 197-202 

ABSTRACT 

Aim Was to compare adult female patients receiving psychiatric 

drugs with obese adult females who didn’t receive any drug treatment 

with respect to the alterations in body weight and biochemistry, 

and find out the contrubution of a team approach for the management 

of these alterations. 

Methods A total of 102 female patients aged mean 40.9±12.4 

years who had been followed up and treated in the Psychiatry Outpatient 

Clinics in Istanbul University for their psychiatric disorders 

and were complaining about increased body weight in the 

treatment period were included. The controls were composed of 

261 females aged mean 39.8±13.0 years who had been referred by 

various departments to dietitians due to exogenous obesity but had 

no endocrine-metabolic or psychiatric disorders or history of drug 

use. Initially, antropometric measurements and biochemical tests 

were performed for all patients. 

Results In the group receiving psychiatric treatment, the mean 

body weight, BMI, waist and hip circumferences, body fat percentage 

(p

198 


INTRODUCTION 

During psychiatric treatment, body weight 

usually increases and this is frequently accompanied 

by an increase in appetite (1). This side effect, 

which is difficult to foresee of its development and 

timing, finally causes obesity and results in the 

cessation of an effective treatment in some of the 

patients. Obesity not only affects the psychological 

state of the patient, but also increases the risk 

of development of several chronic diseases such 

as coronary artery disease, hypertension, hyperlipidaemia, 

diabetes, some types of cancer, cerebrovascular 

diseases, osteoarthritis, pulmonary diseases 

and sleep apnoea (2-4). Therefore, reduction of 

body weight plays a pivotal role in the prevention 

of several chronic diseases and improvement of 

the prognosis of an ongoing disease. 

In this research, we aimed to compare the 

changes in anthropometric and biochemical parameters 

in patients treated with psychiatric drugs 

with ones who did not, and to find out the contrubution 

of a dietitian specialized in this area for the 

treatment of nutrition related metabolic problems 

arising out of psychiatric pharmacotherapies. 

PATIENTS AND METHODS 

In order to determine patients’ group for this 

research the records of all patients who addmitted 

to outpatient clinic of Psychiatric Department 

in Cerrahpasa Medical Faculty University of Istanbul 

in the 2004 to 2008 period retrospectively 

analyzed. It has chosen two groups among 363 

patients who suffer from obesity and were followed 

by a dietician. All patients are informed 

and accepted their inclusion in the research. 

The study group included 102 (28.1%) adult 

female patients taking psychiatric pharmacotherapies 

and complained about increased body weight 

within this period. The mean ±SD age of study 

group was 40.9±12.44 years. 

Medications that patients in the study group 

have taken were antipsychotics 34 (38,2%), mood 

stabilisers 36 (40,4%), antidepressants 72 (80,9%) 

or anxiolytic 9 (10,1%) which were mostly taken 

as combined pharmacotherapy. 

The controls included 261 (71.9%) adult 

females who had no endocrine, metabolic or 

psychiatric disorders or history of drug use and 

had been referred to dietitians due to exogenous 

obesity. The mean ±SD age of control group was 

39.8±13.0 years. 

As body composition depends on age, sex 

and severity of obesity (5, 6) both groups included 

adult females with body-mass index (BMI) ≥25. 

All patients underwent antropometric assessment, 

body composition analysis using a Bioelectrical 

Impedance Analyzer (Bodystat Quadscan 4000, 

England). Biochemical parameters of patients 

were studied with overnight fasting blood samples 

taken from the antecubital vein. Biochemical parameters, 

serum fasting blood glucose (FBG), total 

protein, albumin, uric acid, triglyceride, and total, 

HDL and LDL cholesterol were measured using an 

Olympus AU 800 autoanalyzer (Olympus, Japan). 

FBG was analysed using the hexokinase method. 

The methods were biuret for total protein, BCG 

for albumin and the uricase / PAP method for uric 

acid. Levels of total, HDL cholesterols and triglycerides 

were measured using enzymatic methods in 

all samples. Serum hsCRP concentrations were 

determined with immunonephelometry using the 

BN II Systems Analyzer (Dade Behring, Malburg, 

Germany). FT3, FT4, third-generation thyroid sitimulating 

hormone (TSH) were measured on Immulite 

2000 (DPC; LosAngeles,USA). FT3 and 

FT4 were measured by a competitive analog-based 

immunoassay. TSH levels were determined by 

two-side chemiluminescent immunometric assay. 

Insulin and cortisol were measured with Immulite 

2000 analyzer (DPC,USA) by chemiluminescent 

immunometric assay. Insulin resistance (IR) was 

determined by HOMA- IR index, e.g. serum insulin 

(mg/dl) x plasma glucose (mg/dl) / 405. Serum 

B12, folic acid levels were measured by radioimmunoassay 

(RIA) (DPC, USA). Plasma level of 

homocysteine was determined by high-performance 

liquid chromatography (HPLC Agilent 1100 

Series), coupled with fluorescence detector. Plasma 

fibrinogen levels were measured by BCT (Dade 

Behring, Malburg, Germany) analyser. Serum zinc, 

and copper concentrations were determined using 

the standard atomic absorption spectrophotometry.

The data have been analysed with the Student’s 

t-test and correlations were calculated using 

Pearson correlation. All data are expressed as 

mean ± standard deviation (SD). 

RESULTS 

The results of anthropometric measurements 

and body composition analyses of study and control 

groups are shown in Table 1, while the biochemical 

parameters are shown in Table 2. 

In the study group, the mean body weight, 

BMI, waist and hip circumferences, the waist/ 

hip ratio, body fat percentage, and serum insulin, 

triglyceride, TSH, fibrinogen and homocysteine 

levels were found to be significantly greater while 

the percent of body water and lean body mass, total 

protein, albumin, zinc and folate levels were 

significantly lower than those of the controls. 

In the study group, there was a positive correlation 

between BMI, waist and hip circumferences, 

body fat percentage, basal metabolic rate, insulin, 

HOMA-IR and ferritin levels (r=0.779, p

200 


r=0.394, p=0.000; r=0.344, p=0.030; respectively), 

but there was a negative correlation between the 

duration of drug treatment and percentage of body 

water, percentage of lean body mass, and albumin 

(r=-0.278, p=0.020; r=0.293, p=0.013; r=-0.415, 

p=0.006; respectively). It has also found a positive 

correlation in the study group between weight 

gain and length of drug treatment, BMI, waist and 

hip circumferences, body fat percentage, insulin, 

TSH and HOMA-IR (r=0.646, p=0.000; r=0.534, 

p=0.000; r=0.504, p=0.000; r=0.511, p=0.000; 

r=0.412, p=0.000; r=0.382, p=0.000; r=0.419, 

p=0.000; r=0.319, p=0.004; respectively), but 

there was a negative correlation between weight 

gain and percentage of body water, percentage of 

lean body mass, LDL-C and folat levels (r=-0,534, 

p=0.000; r=-0.388, p=0.001; r=-0.283, p=0.010; 

r=-0.247, p=0.041; respectively). 

DISCUSSION 

Abdominal obesity is strongly associated with 

disorders of glucose, insulin and lipid metabolism 

(7-11). Waist circumference is among the fixtures 

of the diagnostic criteria of metabolic syndrome 

(12). In people with abdominal obesity, the presence 

of at least the two of the diagnostic criteria 

is regarded as indicative of metabolic syndrome 

(12). In these people, high serum uric acid, leptin, 

insulin, and CRP levels and high plasma fibrinogen 

as well as clinical depression, non-alcoholic 

steatosis, and policystic ovary syndrome are more 

commonly encountered (12, 13). Recent studies 

have also indicated the association of insulin resistance 

and impaired glucose tolerance with decreased 

cortical functions and Alzheimer’s disease 

(AD) (14-20). In our study, higher levels of FBG, 

serum insulin, triglycerides and homocysteine levels 

in the study group (Table 2) may indicate that 

these patients have greater risk of not only cardiovascular 

and metabolic diseases, but also of AD. 

In our study, the group receiving pharmacotherapy 

had a mean HOMA-IR value which was 

significantly greater than that of the controls. Besides, 

the extremely significantly greater BMI, 

waist and hip circumferences, waist/hip ratio, 

body fat percentage and fasting blood insulin 

values in the study group as compared with the 

controls also are findings compatible with the diagnostic 

criteria of metabolic syndrome (Tables 1 

and 2). Metabolic syndrome has been reported to 

be considerably prevalent among patients treated 

for schizophrenia (21). This situation indicates 

significantly increased risks of cardiovascular and 

metabolic disorders. Therefore, evaluation and 

follow-up of the risks associated with metabolic 

syndrome should be part of the clinical treatment 

in patients treated with antipsychotics. 

The influence of psychopharmacological 

treatment on body weight does not only vary with 

the drug classes, but also among patients receiving 

the same treatment (22). Clinical parameters 

that may explain the increased body weight include 

the duration and dosage of treatment, duration 

of the disease, clinical response, age, sex, 

smoking, BMI, environmental factors, prominent 

alteration of appetite, deviation from the normal 

body weight at the beginning of treatment, and 

drug-induced activation of the tumor necrosis 

factor (TNF) system (23-25). Many authors have 

reported that increased weight gain is correlated 

with improved clinical symptoms (26-28). 

In the present study, majority of patients on 

psychiatric pharmacotherapy use more than one 

drug. In addition, the proportion of antidepressant 

users was the highest (80.9%). It is possible that individual 

factors may have contributed to significant 

weight gain as well as the effect of antidepressants 

on appetite and body weight. When the factors such 

as premobid body weight, tendency to metabolic 

diseases, nutritional and physical activity habits, 

and coping levels with modification in appetite and 

sedation caused by psychotropic drugs are considered 

together, it may be possible to explain the 

development of weight gain and its relation with 

risk factors (26). Therefore, our suggestion is that 

patient should be evaluated in terms of other hormonal 

metabolic disorders that may develop during 

treatment, in addition to psychiatric disorders, and 

should be followed during the course of treatment. 

Chronic lithium treatment has been shown 

in several studies to cause increased body weight 

(29-30). The extent of this increment varies among 

reports. It has been reported that weight gain occurs 

within the first 2 years, and body weight does

not increase significantly despite continuation 

of lithium intake (31, 32). Not all of the patients 

underwent lithium treatment in our study; however, 

thyroid stimulating hormone (TSH) levels 

were significantly higher in the study group than 

the controls. Because slowing down the functions 

of thyroid gland would contribute to obesity and 

other related risk factors by decreasing the basal 

metabolic rate, patients should be followed up regarding 

this issue. 

Recent studies have proposed that clozapine, 

an atypical antipsychotic, is associated with insulin 

resistance (22, 26). It has been suggested that hyperleptinemia 

may form an important link between 

the development of obesity and insulin resistance 

syndrome, particularly in patients using atypical antipsychotics 

such as clozapine (22-24, 33). The majority 

of patients examined in our study used polypharmacy, 

which makes it difficult to ascribe insulin 

resistance established in the study group to solely 

antipsychotic use. In one study, a positive correlation 

was found between body fat and fibrinogen, 

while plasma leptin concentrations were shown to 

be correlated with fibrinogen and CRP (33). In our 

study, the mean fibrinogen level in the group receiving 

drugs was significantly higher from those 

of the controls (Table 2). While CRP was high in 

both groups (normal values; 0 to 5 mg/L), cortisol 

levels were higher in the study group. It is thought 

that higher cortisol levels in psychiatric patients 

are associated with their endogenous stress, and increased 

preference of sweet foods may be a mechanism 

developed for coping with this stress (8). 

In this study, we have found that while the 

body weight, waist circumference and body fat 

ratio increase in patients undergoing pharmacotherapy 

for psychiatric disorders, increased 

circulating glucose, insulin, triglyceride and homocysteine 

levels accompanied by increased 

REFERENCES 

1. 

2. 

Ozenoğlu A. Changes in appetite and body weight 

during tretament of psychiatric diseases and approaches 

to overcome them. Diabet Bilimi 2006; 

4:34-50. 

Aronne LJ. Epidemiology, morbidity and treatment 

of overweight and obesity. J Clin Psychiatry 

2001; 62 (Suppl):13-22. 

Ozenoglu et al Body weight and psychotropic drugs treatment 

proinflammatory cytokines render these patients 

more susceptible to various metabolic and cardiovascular 

problems. Therefore, we conclude that 

it would be useful if candidates for psychiatric 

pharmacotherapy treated with multidiscipliner 

team approach consisting of an endocrinologist, 

psychiatrist and a dietitian to prevent or delay the 

metabolic disorders developing along with the 

psychiatric disorders and treatments. 

Although the importance of team approach 

in the management of complex diseases has been 

stressed adequately in the literature, in clinical 

practice, while the dominant problem of the patient 

is given priority, other problems that may 

develop in time may be neglected. If a dietitian 

experienced in and informed on particularly disorders 

associated with endocrine metabolism and 

psychiatry fields and who is skilled in communicating 

with patientsis included in the team, he/ 

she may serve as a bridge in cooperating with 

other units and in maintaining this cooperation. 

In the present study, it was established that a dietitian 

experienced in and informed on this field 

may assume an important role in the treatment of 

nutritional, metabolic and cardiovascular diseases, 

which may develop in addition to psyhiatric 

disorders in patients receiving psyschiatric treatment. 

However, it will not always be posssible to 

consult endocrinologists and dietitians for each 

patients receiving psychiatric treatment in the 

clinic. Therefore, family physicians and young 

psychiatrists should also be aware of the impact 

of various diseases and drug treatments on appetite 

and body weight and cardiometabolic diseases 

that may develop during treatment. 


3. 

4. 

5. 


Rosmond R, Björntorp P. The role of antidepressants 

in the treatment of abdominal obesity. Med 

Hypotheses 2000; 4:990-4. 

Ozenoglu A. Medical nutrition treatment of obesity. 

Istanbul: Dilek Basımevi, 2001. 

Ozenoglu A, Can G, Hatemi H. Reference parameters 

of body composition among man and women 

with normal weight, overweight, obesity and morbid 

obesity acoording to their BMI. Endokrinolojide 

Yonelisler 2001;10:58-63. 

201

202 


6. Ozenoğlu A, Sahin E, Can G, Balci H, Uğur A, hypothesis. J Gerontol A Biol Sci Med Sci 2004; 

Hatemi H. Differences in biochemistrical param- 59:178-83. 

eters and body composition among adult women 

with normal weight, overweight, obesity and morbid 

obesity acoording to their BMI. Diabet Bilimi 

2006; 4:122-26. 

21. De Hert MA, Van Winkel R, Van Eyck D, Hanssens 

L, Wampers M, Scheen A, Peuskens J. Prevalance 

of the metabolic syndrome in patients with schizophrenia 

treated with antipsychotic medication. 

7. Rosmond R, Björntorp P. Endocrine and metabolic Schizoph Res 2006; 83:87-93. 

aberrations in men with abdominal obesity in relation 

to anxio-depressive infirmity. Metabolism 

1998; 47:1187-93. 

22. Allison DB, Casey DE. Antipsychotic-induced 

weight gain: a review of the literature. J Clin Psychiatry 

2001; 62 (Suppl):22-31. 

8. 

9. 

10. 

Rosmond R, Dalman MF, Björntorp P. Stress-related 

cortisol secretion in men: relationships with 

abdominal obesity and endocrine, metabolic and 

hemodynamic abnormalities. J Clin Endocrinol 

Metab 1998; 83:1853-59. 

Björntorp P, Holm G, Rosmond R. Hypothalamic 

arousal, insulin resistance and Type 2 diabetes mellitus. 

Diabet Med 1999; 16:373-83. 

Rosmond R, Björntorp P. The hypothalamic-pituitary-adrenal 

axis activity as a predictor of cardiovascular 

disease, type 2 diabetes and stroke. J 

Intern Med 2000; 247:188-97 

23. 

24. 

25. 

Blin O, Micallef J. Antipsychotic associated weight 

gain and clinical outcome parameters. J Clin Psychiatry 

2001; 62 (Suppl):11-21. 

Hummer M, Kemmler G, Kurz M, Kurzthaler I, 

Oberbauer H, Fleischhacker WW. Weight gain induced 

by clozapine. European Neuropsychopharmacol 

1995; 5:437-40. 

Hinze-Selch D, Schuld A, Kraus T, Kühn M, Uhr 

M, Haack M, Pollmächer T. Effects of antidepressants 

on weight and on the plasma levels of leptin, 

TNF-alpha and soluble TNF receptors: a longitudinal 

study in patients treated with amitriptyline 

11. Rosmond R, Björntorp P. Blood pressure in relation or paroxetine. Neuropsychopharmacology 2000; 

to obesity, insulin and the hypothalamic-pituitary- 23:13-9. 

adrenal axis in Swedish men. J Hypertens 1998; 

16:1721-6. 

26. Zimmermann U, Kraus T, Himmerich H, Schuld 

A, Pollmächer T. Epidemiology, implications 

12. Alberti KGMM, Zimmet P, Shaw J. Metabolic Syn- and mechanisms underlying drug-induced weight 

drome- a new world-wide definition. A Concensus gain in psychiatric patients. J Psychiatr Res 2003; 

Statement from the International Diabetes Federa- 37:193-220. 

tion. Diabetic Medicine 2006; 23:469-80. 27. Klett CJ, Caffey EM Jr. Weight changes during 

13. Groop L, Orho-Melander M. The dysmetabolic treatment with phenothiazine derivatives. J Neu- 

syndrom. J Intern Med 2001; 250:105-20. 

ropsychiatr 1960; 2:102-8. 

14. Nicolls MR. The clinical and biological relation- 28. Singh MM, De Dios LV, Kline NS. Weight as a corship 

between Type II diabetes mellitus and Alzhe- relate of clinical response to psychotropic drugs. 

imer’s disease. Curr Alzheimer Res 2004; 1:47-54. Psychosomatics 1970; 11:562-70. 

15. de la Monte SM, Wands JR. Review of insulin 29. Baptista T, Teneud L, Contreras Q, Alastre T, Burand 

insulin-like growth factor expression, signal- guera JL, de Burguera M, de Baptista E, Weiss S, 

ing and malfunction in the central nervous system: Hernàndez L. Lithium and body weight gain. Phar- 

relevance to Alzheimer’s disease. J Alzheimers Dis macopsychiatry 1995; 28:35-44. 

2005; 7:45-61. 

30. Garland EJ, Remick RA, Zis AP. Weight gain with 

16. Yaffe K, Kanaya A, Lindquist K, Simonsick EM, antidepressants and lithium. J Clin Psychopharma- 

Harris T, Shorr RI,et al. The metabolic syndrome, colog 1988; 8:323-30. 

inflammation, and risk of cognitive decline. JAMA 

2004; 292:2237-42. 

31. Vestergaard P, Poulstrup I, Schou M. Prospective 

studies on a lithium cohort 3. Tremor, weight gain, 

17. Luchsinger JA, Mayeux R. Cardiovascular risk fac- diarrhea, psychologic complaints. Acta Psychiatr 

tors and Alzheimer’s disease. Curr Atheroscler Rep Scand 1988; 78:434-41. 

2004; 6:261-6. 

32. Kerry RJ, Liebling LI, Owen G. Weight changes in 

18. Kornhuber HH. Prevention of dementia (including lithium responders. Acta Psychiatric Scand 1970; 

Alzheimer’s disease). Gesundheitswesen. 2004; 46:238-43. 

66:346-51. 

33. Gómez-Ambrosi J, Salvador J, Páramo JA, Orbe 

19. Watson GS, Craft S. Modulation of memory by in- J, de Irala J, Diez-Caballero A, Gil MJ, Cienfue- 

sulin and glucose: neuropsychological observations gos JA, Frühbeck G. Involvement of leptin in the 

in Alzheimer’s disease. Eur J Pharmacol 2004; 490: association between percentage of body fat and 

97-113. 

cardiovascular risk factors. Clin Biochem 2002; 

20. Rasgon N, Jarvik L. Insulin resistance, affective 

disorders, and Alzheimer’s disease: review and 

35:315-20.


Klinička revizija lipidnog statusa kod tipa 2 dijabetesa na nivou 

timova porodične/obiteljske medicine u općini Zenica, Bosna i 

Hercegovina 

Larisa Gavran 1 , Selmira Brkić 2 

1 Edukativni centar porodične medicine “Travnička”, Dom zdravlja Zenica, 2 Medicinski fakultet Univerziteta u Tuzli; Bosna i Hercegovina 


Larisa Gavran, 

Edukativni centar porodične medicine 

“Travnička”, 

Dom zdravlja Zenica, 

Fra Ivana Jukića 2, Zenica, 


Phone:++387 32 461 031; 

E-mail: gavranlarisa@yahoo.com 


22. septembar 2008.; 


14. decembar 2008.; 

Prihvaćeno: 

31. mart 2009. 

Med Glas 2009; 6(2): 203-210 

SAŽETAK 

Cilj Cilj ove studije jeste istražiti da li su timovi porodične/obiteljske 

medicine (TOM) u općini Zenica, nakon uvođenja posebnog kartona 

za dijabetes (PKD), mogli dovesti do poboljšanja kontrole 

nivoa lipida za pacijente oboljele od dijabetes melitusa (DM) tipa 

2, prema preporučenim smjernicama. 

Metode Klinička revizija prakse bila je izvedena pregledom kartona 

pacijenata oboljelih od DM-a tipa 2, starijih od 18 godina, za 

19 timova porodične/obiteljske medicine u Zenici, dvije godine 

prije (2003-2005) i dvije godine poslije (2005-2007) implementacije 

vodiča za DM. Podijelili smo sve zabilježene vrijednosti lipida 

i sve TOM na one koji su dostigli optimalni nivo (UK < 4.5 

mmol/l; LDL- kolesterol < 2.5 mmol/l; TG < 1.7 mmol/l) i one 

koji to nisu (neoptimalni nivo UK > 4.5 mmol/l; LDL- kolesterol 

> 2.5 mmol/l; trigliceride > 1.7 mmol/l). 

Rezultati Pregledana su 853 kartona pacijenata oboljelih od DM 

tipa 2, 46 po jednom TOM-u. Od 19 voditelja TOM-a, četiri (21%) 

su bili muškog i 15 (79%) ženskog spola. Prosječna starosna dob 

iznosila je 46,6 godina. Ustanovljen je statistički značajan napredak 

za optimalni nivo za LDL - kolesterol (19 u odnosu na 531; p < 

0.0001), kolesterol (67 u odnosu na 212; p < 0.0001) i trigliceride 

(227 u odnosu na 463; p < 0.0001) u periodu prije implementacije 

PKD-a u odnosu na period poslije. Statistički značajan napredak 

optimalnog nivoa za trigliceride po timovima nađen je za 10 od 19 

TOM (P < 0.0001). 

Zaključak Nakon implementacije vodiča za kontrolu lipida kod 

DM tip 2 pacijenata, većina TOM-a unaprijedila je optimalni nivo 

lipida. 

Ključne riječi: lipidi, diabetes mellitus, vodiči, timovi porodične/ 

obiteljske medicine 

203

204 


UVOD 

Diabetes mellitus (DM) tip 2 je heterogeni 

poremećaj kompleksne etiologije koji se javlja 

kao odgovor na genetske utjecaje i utjecaje 

spoljne sredine. Centralni događaj u razvoju 

DM-a jesu insulinska rezistencija i poremećena 

sekrecija insulina, mada još uvijek ima oprečnih 

stavova šta je primarni poremećaj (1, 2). 

Širom svijeta suočeni smo sa povećanom prevalencijom 

obolijevanja od dijabetes melitusa tipa 2 

zbog povećanja gojaznosti i smanjenog nivoa aktivnosti 

(1, 3). Morbiditet i mortalitet od komplikacija 

DM-a može se uveliko smanjiti pravovremenim i 

stalnim procedurama kontrole. Ovi metodi skrininga 

indikovani su za sve osobe sa DM-om, mada su 

brojne studije pokazale kako najveći broj osoba sa 

dijabetesom ovu bolest sveobuhvatno ne liječi (4 

- 7). Skrining za dislipidemiju i hipertenziju treba 

da se izvodi svake godine (1). DM tipa 2 prisutan 

je u oko 90% svih slučajeva dijabetesa. Najučestalija 

dislipidemija u tipu 2 dijabetesa sastoji se od 

hipertrigliceridemije, niskog HDL-kolesterola, tzv. 

‘’dobri kolesterol’’ i normalnog LDL-kolesterola, 

tzv. ‘’loši kolesterol’’ (8). 

Klinički vodiči prakse (KVP) sistematski su 

razvijane preporuke koje pomažu liječniku i pacijentu 

u donošenju odluke u specifičnim kliničkim 

okolnostima odgovarajuće zdravstvene njege (9). 

Koristi od vodiča u kliničkoj praksi su višestruke. 

Za naše istraživanje bilo je značajno iskoristiti upute 

zasnovane na dokazima i omogućavati postizanje 

ocjene i osiguranje kvalitetne zaštite pregledom 

kliničkog kvaliteta (auditom) (10). Naprimjer, 

Američka asocijacija za dijabetes (American 

Diabetic Association, ADA) objavi četiri vodiča 

godišnje za nekoliko promjenjivih faktora rizika 

za kardiovaskularne bolesti, uključujući kontrolu 

glikemije, krvnog tlaka i koncentracije lipida 

u krvi (4, 11). Prema preporukama Kanadske 

dijabetološke asocijacije (Canadian Diabetic Association, 

CDA) jedna od komponenti prvog i tzv. 

‘’follow up’’ posjeta dijabetičara liječniku jeste 

metabolička kontrola i evaluacija faktora rizika: 

glukoza natašte, HbA1c, profil lipida natašte, 

mikroalbuminurija, serum kreatinin, izračunavanje 

kreatinin klirensa, elektrokardiogram, pregled 

stopala (monofilamentom ili vibracijom velikog 

prsta stopala), indeks tjelesne mase (BMI), krvni 

tlak, thyroid-stimulirajući hormon (kod svih pacijenata 

sa tipom 1 dijabetesa; kod pacijenata sa 

tipom 2 samo ako je klinički indicirano) (8). 

Dijabetes je sedmi vodeći razlog posjeti 

liječniku primarne zdravstvene zaštite, PZZ (12, 

13). Dugotrajna socijalna i ekonomska korist, 

koja se postiže dobrom kontrolom nivoa glukoze 

i unapređenjem kvalitete njege, trebala bi stimulirati 

liječnike PZZ-a da svakodnevno rade po 

kliničkim vodičima prakse (14). Studije u Europi 

i svijetu, koje su uključivale liječničke prikaze, 

revizije prakse i pregled administrativnih podataka, 

pokazale su da je kvalitet kontrole DM-a 

od strane liječnika PZZ-a suboptimalan. Zapravo 

iste studije ukazuju na korisne intervencije na 

nivou PZZ-a koje mogu dovesti do signifikantnog 

poboljšanje kvalitete njege za dijabetes (4, 6, 

12, 15, 16 - 18). 

Većina razvijenih zemalja ima program za 

nadzor kroničnih bolesti kao što je DM (19). Bosna 

i Hercegovina i dalje nema takvog nacionalnog 

programa. Donešene su određene zakonske 

odredbe kojima se afirmira izrada takvih programa 

i objavljeni akreditacijski standardi za timove 

porodične/obiteljske medicine (Agencije za kvalitet 

i akreditaciju u zdravstvu Federacije Bosne i 

Hercegovine, AKAZ FBiH) koji očekuju od tima 

da “tretira pacijente s hroničnim oboljenjima u 

skladu sa savremenim saznanjima i vodiljama za 

kliničku praksu“ (20). 

Svi stanovnici koji mjestom stanovanja gravitiraju 

najbližoj ambulanti porodične/obiteljske 

medicine u općini Zenica, u kojima je rađena 

studija, registrirani su kod određenog liječnika 

koji je odgovoran u prosjeku za oko 2.543 pacijenta. 

Upravni odbor Zavoda zdravstvenog osiguranja 

Zeničko-dobojskog kantona, u maju 2005. 

godine, donio je Odluku za usvajanje osnovnih 

uslova potrebnih za priznavanje porodične/ 

obiteljske medicine na području Zeničkodobojskog 

kantona (OUPPM-ZDK), a jedan od 

uslova je i dokument pod nazivom Uspostavljanje 

sistema aktivnog nadzora nad dijabetesom 

i hipertenzijom (broj: 01-100-22/05).

Posebni karton za dijabetes (PKD) sadrži 13 

parametara (8 brojčanih i 5 opisnih) za praćenje, 

od kojih se za DM tip 2 – svaka tri mjeseca prati 

vrijednost šećera u krvi natašte, ishrana, aktivnost, 

tjelesna težina i krvni tlak; svakih šest mjeseci kolesterol, 

trigliceridi, proteini u urinu, te pregled 

stopala; a kreatinin, EKG, te pregled fundusa oka 

jedanput godišnje. PKD su bili distribuirani svim 

ordinacijama porodične/obiteljske medicine u 

ZDK, u periodu januar-februar 2006. godine. 

Cilj kliničke revizije (audita) lipidnog statusa 

kod tipa 2 dijabetesa bio je istražiti da li su timovi 

porodične/obiteljske medicine (TOM) u Zenici, 

nakon uvođenja posebnog kartona za dijabetes 

(PKD), mogli dovesti do poboljšanja kontrole 

nivoa lipida za svoje pacijente sa DM-om tipa 2 

prema preporučenim smjernicama. 

PACIJENTI I METODE 

Provedena je audit-studija u Domu zdravlja 

u Zenici, u deset ambulanti porodične/obiteljske 

medicine. U istraživanju su analizirani podaci 

iz perioda maj 2003. – maj 2007. godine. Ovim 

istraživanjem kompariran je nivo evidentiranih 

parametara prije i poslije implementacije posebnog 

kartona za dijabetes (PKD). Podaci iz PKD-a 

pregledani su u periodu dvije godine prije (2003. 

- 2005.) i dvije godine poslije (2005. - 2007.) implementacije 

posebnog kartona za dijabetes. 

Studijom su obuhvaćeni pacijenti oboljeli od dijabetes 

melitusa tipa 2, oba spola, stariji od 18 godina. 

Analizirani su podaci za ukupno 843 pacijenta. 

Devetnaest liječnika porodične/obiteljske 

medicine u Zenici, odnosno 19 timova porodične/ 

obiteljske medicine (TOM), učestvovalo je u 

studiji i omogućilo uvid u medicinske kartone 

oboljelih pacijenata od dijabetes melitusa. Jedan 

liječnik specijalista porodične/obiteljske medicine 

odbio je sudjelovati u istraživanju. 

Za svakog od ovih liječnika uzorak pacijenata 

sa DM-om bio je izabran na osnovu slijedećih 

kriterija: dob pacijenta od 18 godina i više (u toku 

izvođenja istraživanja); dijagnosticiran DM prema 

međunarodnoj kvalifikaciji bolesti - 9 reviz- 

Gavran et al Klinička revizija lipidnog statusa 

ija (E11, E10 ili DM tip 2); redovitost dolazaka 

pacijenta u periodu istraživanja; najmanje jedan 

dolazak pacijenta prije i jedan dolazak poslije implementacije 

PKD-a; pacijenti koje je obiteljski 

liječnik češće sam pregledao i uputio na pretrage 

bez prethodne konsultacije liječnika specijaliste. 

Slučajnim odabirom pregledani su kartoni 

pacijenata praćenih od strane jednog liječnika, a 

koji su zadovoljili kriterije. Za svakog pacijenta 

iz kartona su, osim rednog broja, dobi i spola, 

uzeti podaci za slijedeće parametre, prije i poslije 

upotrebe PKD-a: zadnji nalaz lipoproteina niskog 

denziteta (LDL-kolesterol), ukupni kolesterol 

(UK-kolesterol) i trigliceridi (TG). 

Podaci iz kartona dokumentirani su na 

posebnim obrascima revizije DM prakse, koji 

su kreirani prema PKD-u. Nivoi vrijednosnih 

parametara preuzeti su iz europskog vodiča u 

prevenciji kardiovaskularnih oboljenja, kojeg 

je objavio Komitet Europskog udruženja kardiologa 

za kliničke vodiče, 2003. (21). 

Vrijednosti evidentiranih parametara označene 

su na slijedeći način: LDL-kolesterol > 2.5 mmol/L, 

kao nedovoljan nivo; LDL-kolesterol < 2.5 mmol/L, 

kao optimalan nivo; UK-kolesterol > 4.5 mmol/L, 

kao nedovoljan nivo; UK-kolesterol < 4.5 mmol/L, 

kao optimalni nivo; TG > 1.7 mmol/L, kao nedovoljan 

nivo; TG < 1.7 mmol/L, kao optimalni nivo. 

S obzirom da je etički komitet ustanove bio tek u 

osnivanju u času početka ove studije, o sprovedbi 

revizije prakse na kartonima pacijenata sa dijabetesom 

tipa 2, saglasnost smo dobili od direktora i 

kolega koji su učestvovali u izvedbi studije. 

U statističkoj obradi podataka korištene su 

standardne metode deskriptivne i inferentne statistike. 

Kako su podaci sa kojima se radilo vezani 

isključivo za učestalost, odgovarajuće statističke 

hipoteze testirane su χ2 testom ili testom proporcija 

(z-test proporcija) koji je analogan Studentovom 

t-testu za brojčane (kvantitativne) podatke. 

Statističke hipoteze testirane su sa nivoom 

signifikantnosti p=0.05, tj. nulta hipoteza jednakosti 

dviju proporcija odbacivana je u korist alternativne 

kod vrijednosti p < 0.05. 

205

206 


REZULTATI 

Ukupno su analizirana 853 kartona bolesnika 

sa šećernom bolesti. U uzorku pacijenata dominirao 

je ženski spol, 538 (63.1%), u odnosu na 

muški, 315 (36.9%) (P < 0.0001). Najviše bolesnika 

bilo je u dobnoj skupini od preko 60 godina, 

603 (70.7%) u odnosu na mlađe bolesnike, 

250 (29.3%). U 19 timova porodične/obiteljske 

medicine ukupno je registrirano 44.008 pacijenata, 

od toga 1.578 sa DM-om. U prosjeku svaki od 

timova imao je registrovanih 2.316 pacijenata, 83 

DM po timu, a revizija prakse po timu odrađena 

je u prosjeku na 45 kartona pacijenata oboljelih 

od DM-a tipa 2. 

S obzirom na stručnost timova najviše su bili 

zastupljeni specijalisti porodične/obiteljske medicine 

(spec. P/OM, 13, 74%), dok je 5 (21%) 

liječnika bilo dodatno educirano iz oblasti porodične/obiteljske 

medicine (engl. programm additional 

training, PAT), a 1 (5%) liječnik bio je na 

specijalizaciji iz porodične/obiteljske medicine. 

Prosječna starosna dob timova iznosila je 46.6 

godina, 4 (21%) uzorka timova bili su muškog, a 

15 (79%) ženskog spola. 

Procent nivoa lipida za nedovoljan i optimalan 

nivo, ukupno za sve timove, statistički 

značajno je promijenjen poslije upotrebe obrasca 

(P < 0.0001) (Tabela 1). 

U Tabeli 2 prikazane su vrijednosti optimalnog 

nivoa lipoproteina niskog denziteta po 

Tabela 1. Vrijednosti lipida, prije i poslije upotrebe posebnog 

kartona za dijabetes, po nivoima evidentiranosti za sve 

timove ukupno* 

LDL 

Prije 

upotrebe 

posebnog 

kartona 

N 

283 

O 

53 

Vrijednost lipida (mmol/L) 

Poslije 

upotrebe 

posebnog 

kartona 

N 

234 

O 

119 

Z 

5.4 

N O 

p 

kartona za dijabetes melitus tipa 2 za timove 1, 2, 

7, 12 i 13 (p < 0.0001), timove 9, 14, 18 i 19 (p < 

0.001), a za tim 6 (p < 0.01) u odnosu na zabilježene 

vrijednosti optimalnog nivoa TG-a u periodu prije 

uvođenja posebnog kartona za dijabetes tipa 2. 

DISKUSIJA 

U istraživanju je sudjelovalo 19 timova 

porodične/obiteljske medicine u općini Zenica, 

tj. 19 liječnika (kao vođa timova) koji su dobrovoljno 

pristali na reviziju prakse kartona njihovih 

pacijenata s DM-om tipa 2. U pomenutih 19 

timova ukupno je bilo registrirano 44.008 pacijenta, 

a od toga 1.578 pacijenata sa dijabetes 

melitusom. Ova zastupljenost vjerojatno je i veća 

jer u Domu zdravlja Zenica ne postoji registar sa 

kontinuiranim uvođenjem oboljelih od dijabetesa 

koji bi se mogao unaprijediti sa budućom kompjuterizacijom 

ambulanti porodične/obiteljske 

Tabela 3. Optimalni nivoi vrijednosti ukupnog kolesterola, 

prije i poslije upotrebe posebnog kartona za dijabetes, po 

timovima porodične/obiteljske medicine* 

Prije upotrebe 

posebnog 

kartona 

Poslije upotrebe 

posebnog 

kartona 

Tim N1 N2 (%) N2 (%) 

Z p 

1 ‡ 41 1 (2.4) 9 22.0 2.7 0.01 

2 † 49 3 (6.1) 12 24.5 2.5 0.01 

3 † 50 3 (6.0) 21 42.0 2.9

208 


Naprotiv, zajedničkom timskom unapređenju 

optimalnog nivoa LDL-a, optimalan nivo vrijednosti 

LDL-a, po timovima pojedinačno, našli 

smo da je statistički značajnije zabilježen poslije u 

odnosu na prije uvođenja PKD-a jedino kod dva 

tima kojeg vode specijalisti P/OM. Tri tima uspjelo 

je statistički značajno dostići optimalan nivo vrijednosti 

ukupnog kolesterola poslije u odnosu na 

prije uvođenja PKD-a. Najbolje statistički značajno 

unapređenje optimalnog nivoa dostignuto je za vrijednosti 

triglicerida i zabilježeno je kod najvećeg 

broja timova (10/19) od kojih je 7/10 specijalista P/ 

OM, 5/10 doeduciranih liječnika iz P/OM i jedan 

specijalizant P/OM. Slične rezultate pokazali su i 

Kirk i sur. revizijom kartona 86 slučajno odabranih 

pacijenata sa DM-om u ambulantama obiteljske 

medicine u SAD-u – ustanovljeno je da unatoč 

statistički značajnom poboljšanju vrijednosti 

promjenjivih parametara faktora rizika, proporcija 

pacijenata koji su imali po vodičima preporučene 

vrijednosti HbA1c, krvnog tlaka i LDL kolesterola, 

nije bila značajno promijenjena (4). 

Gill i Di Prinzio u istraživanju, sprovedenom 

2004. godine, o utjecaju upotrebe unificiranih 

vodiča (UKV) za dijabetes na kvalitet njege (258 

kartona dijabetičara u 28 ambulanti obiteljske 

medicine) ustanovili su da nije bilo statistički 

značajne promjene kod većine kvalitativnih indikatora 

godinu prije i godinu poslije implementacije 

UKV. U drugoj analizi istog istraživanja 

liječnici koji su koristili obrasce za praćenje imali 

su bolju kvalitetu njege za većinu mjerenja premda 

nisu bile za sva mjerenja ujednačeno bolja (23). 

Naša studija je pokazala kako je upotreba 

PKD-a pomogla da se unaprijedi praćenje za 

većinu zadatih parametara, zbirno za sve timove, 

kao i da je za veliki broj timova pojedinačno 

(10/19), a koje su većinom činili specijalisti POM, 

statistički značajno bio dostignut optimalni nivo 

parametra triglicerida nakon uvođenja upotrebe 

PKD-a u odnosu na period prije uvođenja. Za ostale 

vrijednosne parametre, LDL i UK, samo su 

neki timovi dosegli optimalne nivoe i to kod LDL-a 

2/19, UK-a 3/19, koji također nisu bili ujednačeni i 

samim tim ne možemo biti zadovoljni. 

U istraživanju primjene preporučenih smjer- 

nica za unapređenje kontrole DM pacijenata 

sprovedenom u SAD-u, ustanovljeno je da su 

razlozi za nepridržavanje smjernica bile razlike 

u znanju liječnika, nepovjerenje u preporučeni 

vodič ili problem vezan za nepridržavanje pacijenata 

datim preporukama od liječnika (11). 

Istraživanjem utjecaja multikomponentnih intervencija 

koje mogu dovesti do unapređenja kvaliteta 

njege za dijabetičare mjerenjem 13 parametara, 

ustanovljeno je kako uključivanje pojedinih 

ambulanti primarne zdravstvene zaštite u povremene 

obilaske i godišnje sastanke, može unaprijediti 

praksu tako da pacijenti dobivaju praćenje 

i tretman, kao i dostizanje ključnih ciljeva za 

HbA1c, lipidni status i krvni tlak (17). 

Istraživanjem nivoa metaboličke kontrole 

kod tipa 2 dijabetičara, vođenih od strane 26 

liječnika na programu dodatne edukacije iz 

porodične/obiteljske medicine u Tuzli, tokom 

2007. godine, ustanovljena je loša metabolička 

kontrola ukupnog kolesterola kod pacijenata tipa 

2 dijabetesa (24). 

Pokazatelji prezentirani u ovoj studiji sugeriraju 

da je primjena posebnog kartona za dijabetes 

na nivou porodične/obiteljske medicine u 

Zenici dovela do unapređenja optimalnog nivoa 

lipida kod većine pacijenata timova porodične/ 

obiteljske medicine i na taj način njihovi su 

pacijenti sa dijabetesom tipa 2 dostigli kliničke 

ciljeve za mjerenje lipida preporučene u europskim 

vodičima (21). 

Ovim istraživanjem ustanovljeno je kako 

je postojeći posebni karton za dijabetes (PKD) 

mogao stimulirati liječnike porodične/obiteljske 

medicine da poboljšaju svoje vještine i znanje, 

te implementiraju klinički vodič prakse u svom 

svakodnevnom radu. S druge strane, potrebno je 

napraviti novo istraživanje koje bi moglo ispitati 

razloge uslijed kojih liječnici porodične/obiteljske 

medicine u općini Zenica nisu dostigli optimalni 

nivo vrijednosti parametara (ukupni kolesterol, 

LDL) po trenutno preporučenim smjernicama. 



ne postoji.

LITERATURA 

1. Powers AC. Diabetes mellitus. U: Harrison TR, 

Braunwald E, Fauci AS, Kasper DL, Hauser SL, 

Longo DL i sur. Načela interne medicine. Knjiga 

2. (15.izd.). Beograd: Bard-fin d.o.o., 2004: 2109- 

37. 

2. Metelko Ž, Granić M, Škrabalo Z. Šećerna bolest. 

U: Vrhovac B, ur. Interna medicina (drugo promijenjeno 

i dopunjeno izdanje). Zagreb: Medicinska 

Naklada, 1997:1365-94. 

3. Bryant W, Greenfield JR, Chisholm DJ, Campbell 

LV. Diabetes guidelines: easier to preach than to 

practice? MJA 2006; 185:305-9. 

4. Kirk JK, Huber KR, Clinch CR. Attainment of 

goals from national guidelines among persons 

with type 2 diabetes: a cohort study in an academic 

family medicine setting. NC Med J 2005; 

66:415-9. 

5. Lawler F, Viviani N. Patient and Physician Perspectives 

Regarding Treatment of Diabetes: Compliance 

with Practice Guidelines. J Fam Pract 

1997; 44:369-73. 

6. Kirkman MS, Williams SR, Caffrey HH, David 

GM. Impact of a program to Improve adherence 

to diabetes guidelines by primary care physicians. 

Diabetes Care 2002; 25:1946-51. 

7. Ornstein S, Nietert PJ, Jenkins GR, Wessell AM, 

Nemeth LS, Feifer C, Corley ST. Improving diabetes 

care through a multicomponent quality improvement 

model in a practice-based research 

network. Am J Med Qual 2007; 1:34- 41. 

8. Anonymous. Canadian Diabetes Association 

Clinical Practice Guidelines Expert Committee. 

Canadian Diabetes Association. Clinical practice 

guidelines for the prevention and management 

of diabetes in Canada. Can J Diabetes 2003; 27 

(Suppl 2): S1-152. www.diabetes.ca/cpg 2003. 

9. Ratsep A, Kalda R, Oja I, Lember M Family doctors‘ 

knowledge and self-reported care of type 

2 diabetes patients in comparison to the clinical 

practice guideline: cross-sectional study. BMC 

Fam Pract 2006; 16:7-36. 

10. Mašić I. Porodična /obiteljska medicina - principi 

i praksa. Medicinski vodiči u praksi. Sarajevo: 

Avicena 2007;125-37. 

11. Anonymous. American Diabetes Association: 

Standard of medical care in diabetes. Diabetes 

Care 2006; 29 (suppl 1):S4-S42. 

12. Worrall G, Freake D, Kelland J, Pickle A, Keenan 

T. Care of patients with type II diabetes: a study of 

family physicians‘ compliance with clinical practice 

guidelines. J Fam Pract 1997;44:374-81. 

Gavran et al Klinička revizija lipidnog statusa 

13. Bodenheimer T, Wagner EH, Grumbach K. Improving 

primary care for patients with chronic illness. 

JAMA 2002; 288:1775-9. 

14. Harris SB, Meltzer SJ, Zinman B. New guidelines 

for the of diabetes: a physician’s guide. Canadian 

Medical Association 1998; 159:973-8. 

15. Harris SB, Stewart M, Brown JB, Wetmore S, 

Faulds C, Webster-Bogaert S, Porter S. Type 2 

diabetes in family practice. Room for improvement. 

Can Fam Physician 2003; 49:778-85. 

16. Ziemer DC, Miller CD, Rhee MK. Clinical inertia 

contributes to poor diabetes control in a primary 

care setting. Diabetes Educ 2005; 31:564-71. 

17. Anonymous. Agency for Healthcare Research 

and Quality. National Healthcare Quality 2005. 

http://www.ahrq.gov/qual/nhdr05/nhdr05.htm 

18. Rothman AA, Wagner EH. Chronic illness management: 

what is role of primary care? Ann Intern 

Med 2003; 138:256-61. 

19. Anonymous. Službene novine Federacije BiH. 

Zakon o sustavu poboljšanja kvalitete, sigurnosti 

i o akreditaciji u zdravstvu 2005; 59:5007-13. 

20. Šabanović F, Selimbašić I, Pavlović J, Leovac Lj, 

Ćepo M, Mercvajer M, Čavkunović M, Trninić 

S, Falak V, Hodžić V, Jatić Z. U: Akreditacijski 

standardi za timove porodične/obiteljske medicine- 

verzija 3.3 (ur.). Riđanović Z, Nakaš B, 

Cerić K. Sarajevo: AVICENA 2005:27-9. 

21. Anonymous. Europski vodič za prevenciju kardiovaskularnih 

bolesti u kliničkoj praksi. Eur Heart 

J 2003; 24:1601-10. 

22. Valk GD, Renders CM, Kriegsman DMW, Newton 

KM, Twisk KMN, Eijk van JThM, Wal van 

der G, Wagner EH. Quality of care for patients 

with Type 2. Diabetes Mellitus Netherlands and 

the United States: a comparison of improvement 

programs. Health Serv Res 2004; 39 (4 Pt 1):709- 

26. 

23. Gill JM, DiPrinzio MJ. The Medical Society of 

Delaware’s Uniform Clinical Guidelines for diabetes: 

did they have a positive impact on quality 

of diabetes care? Del Med J 2004; 76:111-22. 

24. Herenda S, Tulumovic A, Omanović S, Jakupović 

B. Metabolic control among type 2 diabetic patients 

in the northeast part of Bosnia and Hercegovina. 

In: Abstract Book of the 14th Wonca Europe 

Conference of ESGP/FM, Wonca Europe 

2008, Istanbul, Turkey, September, 2008:290-1. 

209

210 


Clinical review of lipids control level for Diabetes Mellitus type 2 

patients done by Family Medicine Teams in Zenica, Bosnia and 

Hercegovina 

Larisa Gavran 1 , Selmira Brkić 2 

1 Family Medicine Teaching Centre Travnička, Health Centre Zenica, 2 Medical Faculty University of Tuzla; Bosnia and Herzegovina 

ABSTRACT 

Aim To assess the effect of the implementation of the guidelines for Diabetes Mellitus (DM) in the 

Family Medicine Teams (FMT) in Zenica municipality using a special flowchart designed for diabetes 

(SFD) to control lipids level improvement in DM type 2 patients. 

Methods The review was conducted among 853 DM Type 2 patients older than 18. In 19 FMTs in Zenica 

we checked patients’ charts made two years before (2003- 2005) and two years after (2005- 2007) 

the implementation of guidelines for DM. We divided all the stablsihed values of lipids and all the FMT 

on the basis of the acievement of an optimal level (cholesterol < 4.5 mmol/L; LDL- cholesterol < 2.5; 

triglyceride < 1.7 mmol/L) and failure to achieve the optimal level (cholesterol > 4.5 mmol/L; LDL- 

cholesterol > 2.5 mmol/L; TG > 1.7 mmol/L). 

Results A total number of 853 DM Type 2 patients’ records were analysed, 46 per one FMT. Four out 

of 19 FMT leaders (21%) were men and 15 (79%) were women. The average age was 46. 6 years. A 

statistically significant improvement for optimal level of LDL - cholesterol (19 vs. 531; p


Učestalost pušenja i nikotinska ovisnost kod medicinskih radnika 

Željko Martinović 1 , Cvita Martinović 2 , Mladen Čuturić 1 

1 Kirurški odjel; 2 Interni odjel, Hrvatska bolnica „Dr. fra Mato Nikolić“, Nova Bila, Bosna i Hercegovina 

Corresponding addres: 

Željko Martinović, 

Hrvatska bolnica „Dr. fra Mato Nikolić“, 

Dubrave bb, 72 276 Nova Bila, 


Phone: ++387 32 708 500; 

E-mail: zeljko.martinovic3@gmail.com 


19. novembar 2008.; 


30. mart 2009.; 

Prihvaćeno: 

13. april 2009. 

Med Glas 2009; 6(2): 211-217 

SAŽETAK 

Cilj Cilj istraživanja bio je utvrditi učestalost pušenja i stupanj 

nikotinske ovisnosti kod aktivnih pušača među medicinskim radnicima. 

Metode Istraživanje je provedeno na uzorku od 66 medicinskih 

radnika Hrvatske bolnice ‘’Dr. fra Mato Nikolić’’ u Novoj Bili, 

metodom ankete i Fagerstromovog modificiranog upitnika za 

procjenu nikotinske ovisnosti. 

Rezultati Od ukupno 66 ispitanika, evidentirali smo 37 (56,1%) 

pušača, 19 (51,4%) žena i 18 (48,6%) muškaraca. Prosječna vrijednost 

skora nikotinske ovisnosti iznosila je 8 bodova što inače 

predstavlja visok stupanj nikotinske ovisnosti. 

Zaključak Pušenje, kao preventabilni zdravstveni faktor rizika, 

predstavlja veliki problem i samim medicinskim radnicima. Oni, 

kao aktivni pušači, imaju visok stupanj nikotinske ovisnosti koja 

zahtijeva stručni tretman. 

Ključne riječi: pušenje, medicinski radnici, stupanj nikotinske 

ovisnosti, Fagerstromov upitnik 

211

212 


UVOD 

U prvim desetljećima dvadesetog stoljeća, 

pušenje je postalo društveno prihvatljiva navika. 

Danas, prema procjeni Svjetske zdravstvene 

organizacije, tu naviku ima 1,3 milijarde ljudi 

i približno 5 milijuna godišnje umire od njenih 

posljedica. Pušenje je tako postala najsmrtonosnija 

pandemija današnjice (1, 2). 

Prvi znanstveni dokazi o štetnim učincima 

pušenja pojavljuju se sredinom prošlog stoljeća. 

Engleski liječnici R. Doll i A. B. Hill 1952. godine 

dokazali su uzročnu povezanost pušenja i 

karcinoma bronha i pluća, infarkta miokarda i 

kronične opstruktivne bolesti pluća (3, 4). 

Američka zdravstvena služba (Surgeon General’s 

Report on Smoking and Health) objavila 

je 1964. godine izvješće o pušenju kao faktoru 

rizika koji znatno pridonosi morbiditetu i mortalitetu 

niza bolesti, a 1975. godine nikotinska 

ovisnost unesena je u Međunarodnu klasifikaciju 

bolesti, ozljeda i uzroka smrti (5). 

Iako predstavlja preventabilan čimbenik 

rizika, prema Svjetskoj zdravstvenoj organizaciji, 

pušenje duhana je drugi vodeći uzrok smrtnosti i 

četvrti zajednički zdravstveni čimbenik rizika u 

svijetu. Ako se nastave sadašnji trendovi pušenja, 

do 2030. godine broj umrlih od bolesti vezanih za 

pušenje duhana mogao bi doseći brojku od 650 

milijuna (6). 

Danas se smatra kako je moguće reducirati 

značajan broj ovih smrtnih ishoda mjerama 

sprječavanja, suzbijanja i prestanka pušenja (7). 

Važnu ulogu u prevenciji i strategiji edukacije 

o prestanku pušenja imaju zdravstveni radnici, 

koji bi inače trebali biti primjer zdravog načina 

života. Međutim, značajan broj zdravstvenih radnika 

nisu uvijek dobar primjer svojim pacijentima. 

Štoviše, mnogi od njih ne smatraju prekid 

pušenja kao visoko prioritetan cilj za svoje 

pacijente, te savjet o potrebi prekida pušenja ne 

vide kao sastavni dio medicinske skrbi. Prema 

objavljenim podacima u različitim studijama, 

učestalost navike pušenja među zdravstvenim 

radnicima je visoka, posebice u državama u razvoju, 

u kojima antipušačke kampanje još nisu 

pokrenute u značajnijoj mjeri, pa tako ni u Bosni 

i Hercegovini (8, 9). 

Cilj ovog istraživanja bio je utvrditi učestalost 

pušenja i stupanj nikotinske ovisnosti kod aktivnih 

pušača medicinskih radnika primjenom 

modificiranog Fagerstromovog upitnika. 

Ako pušite, molimo Vas, da odgovorite na slijedeća 

pitanja na način da križićem označite Vaš odgovor 

1. Koliko cigareta dnevno pušite? 

1-10 

11-20 

21-30 

31 i više 

2. Kakve cigarete pušite? 

€ 

€ 

slabe (do 0,9 mg nikotina) 

srednje (1,0-1,2 mg nikotina) 

€ jake (1,3 mg i više nikotina) 

3. Da li uvlačite dim cigarete? 

€ 

€ 

nikad 

ponekad 

€ uvijek 

4. Kada nakon buđenja zapalite svoju 

€ u prvih 5 minuta 

prvu cigaretu? 

€ unutar 6-30 minuta 

€ unutar 31-60 minuta 

5. Kad više pušite? 

€ u toku prijepodneva 

€ u toku ostalog dijela dana 

6. Koje cigarete biste se najteže odrekli? 

€ prve jutarnje 

€ bilo koje druge 

7. Da li Vam je teško suzdržati se od 

€ ne 

pušenja na mjestima gdje je to zabranjeno? 

€ da 

8. Da li pušite i kada ste bolesni? 

€ ne 

€ da 

Odgovor Bodovi* 

*Nikotinski skor ovisnosti: 0-2 vrlo niska; 3-4 niska; 5-6 umjerena; 7 i više bodova - visoka i vrlo visoka 

Slika 1. Modificirani Fagerstromov upitnik za procjenu nikotinske ovisnosti 

0 

1 

2 

3 

1 

2 

3 

0 

1 

2 

3 

2 

1 

1 

0 

1 

0 

0 

1 

0 

1


Istraživanje je provedeno na slučajnom 

uzorku od 66 ispitanika medicinskih radnika 

(liječnici, medicinske sestre i tehničari) Hrvatske 

bolnice ‘’Dr. fra Mato Nikolić’’ u Novoj Bili, 

metodom ankete. Anketni listić sadržavao je podatke 

o pušenju, pušačkom stažu, godinama starosti 

i spolu, te Fagerstromov modificirani upitnik 

za procjenu nikotinske ovisnosti (10). 

Modificirani Fagerstromov upitnik (Slika 1) 

sastojao se od osam pitanja. Odgovori na pitanja 

bodovali su se od 0-3 boda, a zbrajanjem je dobiven 

skor nikotinske ovisnosti (raspon od 2 do 

15 bodova). Skor od 2-6 bodova označavao je 

nisku do umjereno tešku nikotinsku ovisnost, a 

skor od 7 i više bodova označavao je teški stupanj 

nikotinske ovisnosti po Fagerstromu. 

REZULTATI 

Od ukupno 66 ispitanika, 36 (54,5%) je bilo 

ženskog, a 30 (45,5%) muškog spola. Prosječna 

starosna dob ispitanika iznosila je 30,34 ± 15,24 

godina. Ispitanika pušača bilo je 37 (56,1%), 

a nepušača 29 (43,9%) (Tablica 1). Nije nađena 

statistički značajna razlika u spolnoj distribuciji ispitanika 

pušača i nepušača (p > 0,05, odnosno p > 

0,01). Prosječna starosna dob ispitanika pušača iznosila 

je 32,05 ± 14,14 godina, a nepušača 28,17 ± 

16,23 godina. Nije nađena statistički značajna razlika 

u starosnoj dobi ove dvije grupe (p > 0,05). 

Prosječan pušački staž iznosio je 13,16 ± 

9,82 godine (raspon 1-34). U Tablici 2 prikazana 

je raspodjela ispitanika prema broju dnevno 

ispušenih cigareta (uglavnom niskog sadržaja 

nikotina). Većina ispitanika pušača više je pušila 

u popodnevnim satima (24, 64,9%). 

Prosječna vrijednost skora nikotinske ovisnosti 

iznosila je 8,08 ± 2,00 (raspon 3-12). Nije nađena 

Muškarci (%) Žene (%) Ukupno (%) 

Pušači 18 (27,3%) 19 (28,8%) 37 (56,1%) 

Nepušači 12 (18,2%) 17 (25,7%) 29 (43,9%) 

Ukupno 30 (45,5%) 36 (54,5%) 66 (100%) 

Martinović et al Učestalost pušenja i nikotinska ovisnost 

statistički značajna razlika u prosječnoj vrijednosti 

nikotinskog skora između ispitanika pušača 

muškog i ženskog spola (p > 0,05). Visok stupanj 

nikotinske ovisnosti nađen je kod 32 (48,5%) ispitanika, 

dok je pet (7,6%) ispitanika imalo nisku do 

umjerenu vrijednost nikotinske ovisnosti. 

Analizom međusobne povezanosti visine skora 

nikotinske ovisnosti i dužine pušačkog staža, 

te broja dnevno popušenih cigareta, utvrđena je 

pozitivna linearna povezanost ovih varijabla. 

Vrijednost koeficijenta korelacije između dužine 

pušačkog staža i skora nikotinske ovisnosti pokazivala 

je neznatnu povezanost između ovih dviju 

varijabla (r = 0,117; 95% CI = -0,2152-0,4249; 

p = 0,4903), a u obje varijable ustanovljeni su 

zajednički činioci (1,36%) (R 2 = 0,0136). Nađena 

je statistički značajna korelacija između broja 

dnevno popušenih cigareta i visine skora nikotinske 

ovisnosti (r = 0,594; 95% CI = 0,3350-0,7701; 

p < 0,0001). U obje varijable ustanovljeno je 

35,3% zajedničkih činilaca (R 2 = 0,3534). 

DISKUSIJA 

Učestalost pušenja duhana u općoj populaciji 

u Bosni i Hercegovini izrazito je visoka. 

Neposredno nakon završetka rata svakodnevno 

je pušilo oko 48% odraslih osoba, dok je, prema 

podacima Svjetske zdravstvene organizacije iz 

2006. godine, ta brojka bila osjetno niža, te je, u 

populaciji odraslih osoba, u dobi između 25. i 64. 

godine, iznosila 37,6% (11, 12). Drugim riječima, 

u Bosni i Hercegovini proširenost navike pušenja 

među najvećim je u državama Balkana (32,4%) i 

EU (29,3%) (11). 

Slična ‘’epidemiološka situacija’’ utvrđena 

je i u populaciji medicinskih radnika. Prema podacima 

iz dostupne literature, učestalost navike 

pušenja u ovoj populaciji u Bosni i Hercegovini 

iznosi oko 48% (9, 13). U 1996. godini, prema 

Tablica 1. Spolna distribucija i distribucija navike pušenja 

Tablica 2. Ispitanici pušači prema broju dnevno popušenih 

cigareta 

ispitanika Broj dnevno popušenih cigareta Ispitanici pušači (%) 

1 – 10 5 (13,5%) 

11 – 20 22 (59,5%) 

21 – 30 9 (24,3%) 

31 i više 1 (2,7%) 

213

214 


podacima Svjetske zdravstvene organizacije, u 

Bosni i Hercegovini svakodnevno je pušilo 55% 

liječnika i 50% liječnica (14). Zastupljenost navike 

pušenja bila je najveća kod medicinskih sestara 

i tehničara (58%) i liječnika opće prakse (oko 

48%), dok je istu naviku imalo oko 43% liječnika 

specijalista (9). 

U usporedbi sa drugim državama Europe, 

učestalost navike pušenja od 48%, među medicinskim 

radnicima u Bosni i Hercegovini, ekstremno 

je visoka. Prema podacima iz literature, slična ili 

veća učestalost navike pušenja kod medicinskih 

radnika, zabilježena je u Grčkoj (39%), Rumuniji 

(42,3%) i Turskoj (oko 52%), dok je u većini 

država EU učestalost navike pušenja ispod 25%, 

s tendencijom stalnog opadanja (15, 16, 17). 

Izrazito niska učestalost ove navike dokumentirana 

je kod medicinskih radnika u SAD-u (2%), 

Australiji (3%) i Engleskoj (3%) (18). 

Učestalost pušenja kod naših ispitanika bila 

je 56,1% i veća je nego u općoj populaciji, i to 

većinom kod zdravstvenih radnika ženskog spola 

(54,5%), što je osobito zabrinjavajuće. Znanstvena 

istraživanja dokazala su negativan utjecaj 

pušenja na reproduktivno zdravlje žena, odnosno 

povećavanje rizika od neplodnosti, ekstrauterine 

trudnoće, spontanog pobačaja, prijevremenog 

poroda i menstrualnih poremećaja (7, 19, 20). 

Udisanje duhanskog dima kod dojenčadi i male 

djece dovodi do učestalije pojave različitih bolesti 

dišnog sustava i oštećenja plućne funkcije, a 

i sindrom iznenadne smrti dojenčeta učestaliji je 

kod dojenčadi koja su bila izložena duhanskom 

dimu (20, 21). 

Više je mogućih uzroka visoke učestalosti 

pušenja kod naših ispitanika. Jedan od najvažnijih 

jeste najvjerojatnije nedavno okončani ratni sukob 

u BiH i veliko breme odgovornosti pred 

zdravstvenim radnicima za život i zdravlje 

njegovih sudionika. Ovakvo razmišljanje potkrijepljuju 

demografski podaci naših ispitanika i podaci 

iz literature (9, 22). Drugi, ne manje važan 

uzrok, jeste općekulturalno prihvaćanje i odobravanje 

pušenja duhana kao društveno prihvatljive 

navike, kako u općoj populaciji, tako i u populaciji 

zdravstvenih radnika. Štoviše, zdravstveni 

radnici, posebice liječnici, predstavljaju jednu od 

društveno utjecajnih grupa kojoj je pušenje prihvatljiva 

navika u različitim socijalnim okolnostima 

kao što su stresne situacije na poslu i profesionalnom 

usavršavanju (9, 22). Treći uzrok leži 

u činjenici da, nažalost, ne mali broj zdravstvenih 

radnika još uvijek pušenje ne prihvaća kao bolest 

ovisnosti, te da ona, kao takva, zahtijeva i adekvatno 

liječenje, a ne samo mjere suzbijanja i 

sprječavanja. Ovakvo razmišljanje podupire i 

srednja vrijednost Fagerstrom nikotinskog skora, 

koja se, kod naših ispitanika, nalazila u rasponu 

vrlo visoke nikotinske ovisnosti. Od ukupnog 

broja pušača u ovom istraživanju, 86,5% odgovorili 

su da uvijek inhaliraju dim iz cigarete, a 84% 

da dnevno popuše 11-30 cigareta, uglavnom niskog 

(0,9 mg) sadržaja nikotina, što odgovara 

prosječnoj dnevnoj dozi od oko 18,5 mg nikotina 

(raspon 10-27 mg). Potrebnu dozu nikotina pušači 

mogu regulirati brojem dnevno popušenih cigareta, 

te brojem i dubinom inhalacija dima iz cigarete 

(7). Štetni učinci duhanskog dima rastu s dozom 

izloženosti. Zbog tih različitosti i stupanj nikotinske 

ovisnosti uveliko varira (7, 20). Sa povećanjem 

broja dnevno popušenih cigareta učestalije se 

javljaju i simptomi nikotinske ovisnosti, te raste 

vrijednost skora nikotinske ovisnosti što upućuje 

na njihovu pozitivnu linearnu povezanost (7, 8, 

20, 23). I dobivena vrijednost koeficijenta korelacije, 

u našem istraživanju, pokazala je da postoji 

stvarna, statistički značajna povezanost između 

visine skora nikotinske ovisnosti i broja dnevno 

popušenih cigareta (p < 0,001). U obje varijable 

ustanovljeno je približno 35,3% zajedničkih 

čimbenika, što upućuje na zaključak o postojanju 

puno većeg broja čimbenika koji utiču na stupanj 

nikotinske ovisnosti kod medicinskih radnika. 

Možemo samo pretpostaviti da veliki udio čine 

psihološki i društveni čimbenici (7, 22). 

Vrijednost koeficijenta međusobne povezanosti 

skora nikotinske ovisnosti i dužine 

pušačkog staža pokazala je neznatnu povezanost 

ovih dvaju varijabla, uz približan 

udio zajedničkih čimbenika od 1,36%. Mnogi 

čimbenici određuju razlike i učinke pušenja među 

pušačima pojedinačno (8, 24). Jedan od njih jeste 

i dužina pušačkog staža, čiji se učinci izražavaju

kroz rizike nastanka i pojave različitih oboljenja, 

kvalitetu i dužinu života pušača, što je u literaturi 

dobro dokumentirano (25, 26). Usprkos tome, 

učestalost navike pušenja među zdravstvenim 

radnicima u mnogim državama Europe i svijeta 

i dalje je visoka. 

Danas postoji široko prihvaćen konsenzus 

o implementaciji strategije o prevenciji i suzbijanju 

pušenja (7, 8). Uloga medicinskih radnika 

u implementaciji ove strategije jeste od esencijalne 

važnosti. Jasno je da visoka učestalost 

navike pušenja među zdravstvenim radnicima 

može povećati neodlučnost i skepticizam prema 

prestanku pušenja i liječenju nikotinske ovisnosti 

kod njihovih pacijenata. To potvrđuju i podaci iz 

literature koji pokazuju da liječnici imaju bolje 

rezultate u uvjeravanju svojih pacijenata na prestanak 

pušenja, ako i oni sami nisu pušači (18). 

Osim izravnog utjecaja na prestanak pušenja 

među pacijentima, medicinski radnici svojim 

učešćem u kreiranju socijalne politike usmjerene 

na sprječavanje i suzbijanje pušenja, mogu imati 

značajan utjecaj na smanjenje stope pušenja u 

općoj populaciji i smanjenju mogućnosti prinudne 

izloženosti duhanskom dimu (‘’pasivnom 

pušenju’’) kroz zakonsko osiguravanje radnih i 

javnih prostora bez duhanskog dima. ‘’Pasivno 

pušenje’’ još uvijek je široko rasprostranjen 

čimbenik rizika u EU. Meta analize provedene u 

EU i SAD-u potvrdile su povezanost ‘’pasivnog 

pušenja’’ sa rakom pluća odraslih i opstruktivnim 

plućnim bolestima kod djece (27). S druge strane, 

pušenje unutar bolničkih prostora nije rijetkost 

LITERATURA 

1. 

2. 

3. 

4. 

WHO. Tobacco or health: a global status report 

WHO. Geneva: WHO, 1997. http://www.who.org 

(24. 2. 2008.) 

WHO. Guidelines for controlling and monitoring 

the tobacco epidemic. Geneve: WHO, 1998. 

http://www.who.org (24. 2. 2008.) 

Doll R, Hill AB. A study of the aetiology of carcinoma 

of the lung. Br Med J 1952; 2:1271–86. 

Doll R, Hill AB. Lung cancer and other causes of 

death in relation to smoking: A second report on 

the mortality of British doctors. Br Med J 1956; 

2:1071–81. 


i ima snažan negativan edukacijski učinak na 

pacijente. Prema podacima iz literature, oko 75% 

medicinskog osoblja, aktivnih pušača, puši izvan 

svog radnog prostora u bolnici, a samo oko trećine 

bolničkog medicinskog osoblja vjeruje da je politika 

‘’bolnicâ bez pušenja’’ uopće provodiva (28). 

Prema našim podacima, više od trećine naših ispitanika 

(35,1%) više su pušili u prijepodnevnim 

satima, odnosno u vrijeme radnog vremena. 

Oko 14% ispitanika pušilo je i unutar prostora 

bolnice. Ova brojka je nešto manja od očekivane 

i rezultat je ranije uvedenih restrikcijskih mjera. 

U Bosni i Hercegovini tek se očekuje intenzivnija 

antipušačka kampanja, posebice na području 

zdravstvene prosvijećenosti i edukacije, te suzbijanju 

i zabrani pušenja u javnim i radnim prostorijama. 

Medicinski radnici bi svakako trebali imati 

vodeću ulogu u potpori takvoj socijalnoj politici, 

posebice u zdravstvenim ustanovama. Naravno, 

zbog visoke učestalosti navike pušenja i visokog 

stupnja nikotinske ovisnosti, i zdravstvene radnike 

trebalo bi uključiti u programe odvikavanja, 

a zatim dodatno educirati i uključiti u timove za 

pružanje savjetodavne i farmakološke pomoći 

u procesu odvikavanja. Kao i druge kronične 

bolesti, i nikotinska ovisnost zahtijeva različite 

modalitete tretmana, te neophodnu dodatnu edukaciju 

zdravstvenih radnika. 



ne postoji. 

5. 

6. 

7. 

Doll R. Tobacco: a medical history. J Urban 

Health 1999; 76:289–313. 

European Commission. Tobacco or health in the 

EU: paste, present and future. 2004. Luxembourg, 

Office of Official publications of the European 

Communities, 2004. http://www.ec.europa.eu/ 

health/ph determinants/life style/Tobacco/Documents/tobacco 

fr.eu.pdf (26. 2. 2008.) 

NIDA Research report series: Tobacco addiction. 

U. S. Department of Health and Human Services. 

National Institute of Health, 2006. http://www. 

nida.nih.gov/PDF/RRTTobacco.pdf. (6. 4. 2008.) 

215

216 


8. Bozicevic I, Gilmore A, Oreskovic S. The tobacco 

epidemic in South-East Europe: concequences 

and policy responses. Economics of tobacco control 

paper N° 8. Health, Nutrition and Population 

(NHP) Discussion Paper. World Bank. Washington, 

2004. (http://www.worldbank.org/tobacco 

(5. 4. 2009.) 

9. Hodgets G, Broers T, Godwin M. Smoking behaviour, 

knowledge and attitudes among Familiy 

Medicine physicians and nurses in Bosnia 

and Herzegovina. BMC Fam Pract 2004; 5: 12. 

http://www.biomedcentral.com/1471-2296/512/ 

(21.1.2008.) 

10. Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom 

K-O. The Fagerstrom Test for Nicotine Dependence: 

a revision of the Fagerstrom Tolerance 

Questionnaire. Br J Addict 1991; 86:1119–27. 

11. Regular daily smoking measured by the Public 

Health Institute; Health for all statistical database. 

WHO Regional Office for Europe. Copenhagen: 

WHO, 2000. http://www.who.int/tobacco/media/ 

en/Bosnia.pdf. (24. 2. 2008.) 

12. European health for all database.WHO Regional 

Office for Europa. Copenhagen: WHO, 2006. 

http://www.data.euro.who.int/hfadb/ 

2008.) 

(24. 2. 

13. Anonimno. Reporting project. Smoking health. 

http://reportingproject.net/new/index.php?option 

=com_content&task=view&id=52&Itemid=47 

(15. 2. 2009.) 

14. WHO European Region’s Tobacco Questionnaire 

1996 / 1997. (information provided by Dr Ajnija 

Omanicin). Estimated regular daily cigarette 

smoking. http://www.tcrc-profiles.globalink.org/ 

ba_tcp.html (26. 2. 2008.) 

15. Sotiropoulos A, Gikas A, Spanou E, Dimitrelos 

D, Karakostas F, Skliros E. Smoking habits and 

associated factors among Greek physicians. Public 

Health 2007; 5 (Suppl):333-40. 

16. Didilescu C, Munteanu I. The prevalence of 

smoking in physicians in Romania. Pneumologia 

2000; 49 (Suppl 2):91-4. 

17. Tezcan S, Yardim N. Prevalence of smoking between 

the doctors, nurses and medical faculty students 

at some health facilities in Turkey. Tuberk 

Toraks 2003; 51(Suppl 4):390-7. 

18. Smith DR, Lagget PA. An international review of 

tobacco smoking in the medical profession: 1974 

-2004. BMC Public Health 2007; 7:115. http:// 

www.biomedcentral.com/1471-2458/7/115 (21. 

1. 2008.) 

19. Seltzer V. Smoking as a risk factor in the health of 

women. Obstet Gynecol 2003; 82:393-7. 

20. Hrabek-Žerjavić V, Kralj V. Umjesto riječi urednice 

teme: Pušenje-čimbenik rizika za zdravlje. 

HČJZ 2007; 11(Suppl 3) http://www.hcjz.hr 

(24.2. 2008.) 

21. Rushton L, Courage C, Green E. Estimation of 

the impact on children’s health of environmental 

tobacco smoke in England and Wales. R Soc 

Health 2003; 123:175-80. 

22. Creston D, Schmitz JM, Aranoutovic A. Warrelated 

changes in cigarette smoking: a survey of 

health professionals in Sarajevo. Subst Usa Misuse 

1996; 31(Suppl 5):639-46. 

23. Krstačić G. Pušenje i krvnožilne bolesti. HČJZ 

2007; 11(Suppl 3) http://www.hcjz.hr (24. 2. 

2008.) 

24. Fiore MC, Jaén CR, Baker TB, et all. Treating Tobacco 

Use and Dependence: 2008 update. Clinical 

Practice Guideline. MD: U.S. Department of 

Health and Human Services. Public Health Service. 

Rockville, 2008. http://www.ahcq.gov/path/ 

tobacco.htm#Clinic. (6. 2. 2009.) 

25. Price JF, Mowbray PI, Lee AJ, Rumley A, Lowe 

GDO, Fowkes FGR. Relationship betwen smoking 

and cardiovascular risk factors in the development 

of peripherial arterial disease and coronary 

artery disease, Edinburgh Artery Study. Eur Heart 

J 1999; 20 (Suppl 5):344-53. 

26. Flanders WD, Lally CA, Zhu BP, Henley SJ, Thun 

MJ. Lung cancer mortality in relation to age, duration 

smoking, and daily cigarette consumption: 

result from Cancer Prevention Study II. Cancer 

Res 2003; 63(Suppl 19):6556-62. 

27. Zhong M, Goldberg S, Parent ME, Hanley JA. 

Exsposure to environmental tobacco smoke and 

the risk of lung cancer: meta-analysis. Lung Cancer 

2000; 14 (Suppl 1):3-18. 

28. Versano S, Hevion G, Garenkin M. Smoking by 

an israeli general hospital staff, and attitude to 

smoking in hospitals. Are we in Israel ready to institute 

„smoke –free hospitals“? Harefuah 2000; 

138(Suppl 4): 335-40. http://www.pubmed.gov 

(21.1.2008.)

Incidence of smoking and nicotine depedence among medical 

workers 

Željko Martinović 1 , Cvita Martinović 2 , Mladen Čuturić 1 

1 Department of Surgery; 2 Department of Internal Medicine, Croatian Hospital “Dr. Fra Mato Nikolić”, Nova Bila 

ABSTRACT 

Aim To determine the frequency of smoking and nicotine dependence level of active smokers among 

medical workers. 

Methods The research encompassed a sample of 66 medical workers of the Croatian Hospital “Dr. Fra 

Mato Nikolić” in Nova Bila using surveys and Fagerstrom’s modified test for nicotine dependence. 

Results There were of 66 examinees,37 (56.1%) of them being smokers, 19 (51.4%) female and 18 

(48.6%) male. The average value of nicotine dependence score was 8 points, which represented a high 

level of nicotine dependence. 

Conclusion Smoking as a preventable health risk factor is a big problem even for medical workers 

themselves. Medical workers, active smokers, have a high level of nicotine dependence requiring a 

professional treatment. 

Key words: smoking, medical workers, level of nicotine dependence, Fagerstorm’s test 


19 November 2008; 


30 March 2009; 

Accepted: 

13 April 2009. 


217

218 


Smoking is the most frequent risk factor for cardiovascular diseases 

in Croatian Western region: findings of the Croatian health 

survey 2003 

\ulija Malatestinić 1 , Nena Rončević 2 , Henrietta Benčević-Striehl 1 , Suzana Janković 1 , Vladimir Mićović 1 

1 Teaching Institute of Public Health of Primorsko-goranska County, University School of Medicine, 2 University School of Philosophy; 

Rijeka, Croatia 


\ulija Malatestinić 

Teaching Institute of Public Health of 

Primorsko-goranska County, 

University School of Medicine 

Krešimirova 52/a, 51 000 Rijeka, Croatia 

Phone: ++385 51 334 530 ; 

Fax.: ++385 51 213 948; 

Email: dulija.malatestinic@zzjzpgz.hr 


11 February 2009; 


17 April 2009; 

Accepted: 04 May 2009. 

Med Glas 2009; 6(2): 218-226 

ABSTRACT 

Aim To estimate the prevalence of selected behavioral risk factors 

for cardiovascular diseases in the western region of Croatia and to 

determine the differences based on age and gender. 

Methods A national survey on health status and health behavior of 

the adult population has been conducted. The representative sample 

of 10,766 households for six officially defined regions of Croatia 

has been determined, and Western region has been included with 

1,562 inhabitants, aged 18 years and older. The overall response 

rate of administered face-to-face questionnaire was 85-6%. Prevalence 

rates per 100 inhabitants (smoking, eating habits, alcohol 

consumption, physical activity, socio-economic characteristics, 

chronic conditions) have been determined. 

Results Nearly half (46.3%) of the adults were smokers or had 

quit smoking less than 10 years ago. Prevalence of high blood 

pressure was high amounting to 40.6% and it was higher in middle 

aged males (46.7%, p

INTRODUCTION 

Cardiovascular diseases (CVDs) are the major 

cause of death in most European transitional 

countries (1). In Croatia CVDs are the leading 

cause of death and account for more than half of 

the overall mortality (2,3). Unfortunately, exact 

data on the spread of the most important risk factors, 

such as hypertension, smoking, obesity, hypercholesterolemia, 

hypertriglyceridemia, insufficient 

physical activity etc. were not available 

prior to Croatian Adult Health Survey (CAHS) in 

2003. It provided timely, reliable, cross-sectional 

estimates, supporting the development of a public 

health information system, health promotion, 

with emphasis on CVD prevention, CVD risk reduction 

and healthier lifestyles promotion among 

the general population (4). Furthermore, there 

have been no systematic and comparable studies 

of the risk factors on a representative sample of 

the population at the national as well as the regional 

level. 

Although CVDs account for more than half 

of the overall mortality in Croatia, the support for 

the research in this area, during the last decade, 

has not been sufficient. In the period between 1991 

and 2004, Croatia had the lowest CVD publication 

rates (in 2003 the estimated proportion was 

1.2% as opposed to 7.3-11.8% in other analysed 

countries) in the MEDLINE database among the 

countries included into the analysis (5). 

The mortality caused by CVDs in the population 

can be significantly reduced by acquiring a 

healthier way of life such as non-smoking, proper 

diet and regular physical activity. It is well known 

that health promotion and primary prevention are 

of substantial importance in decreasing CVD 

mortality and morbidity (5). 

One of the main hypotheses in our research 

program on health status and health behavior in 

adult population of the Croatian Western region 

was a high prevalence of CVDs risk factors with 

gender and age differences and different hierarchy 

in the prevalence of selected behavioral risk factors 

for CVDs as compared with the national level. 

Malatestinićet al Smoking in the Croatian Western Region 

PARTICIPANTS AND METHODS 

Participants 

The data were collected in the summer of 

2003, and results have been officially released in 

December 2003 in the cross-sectional survey entitled 

“Croatian Adult Health Survey” (CAHS) 

(6). The main goal of the survey was to examine 

the health status, risk factors and health care utilization 

with a focus on cardiovascular diseases 

(CVDs). Conceptually, the survey was based on 

existing studies such as the CINDI (7,8), and Short 

Form 36 of the World Health Organization (9). 

The development, design and implementation 

of the 2003 CAHS was conducted by 

the Canadian Society of International Health, 

Croatian Ministry of Health, Croatian Central 

Bureau of Statistics, Andrija Štampar School of 

Public Health and the National Institute of Public 

Health, Zagreb, Croatia, and the cooperation resulted 

in completion of a high quality population 

health survey that provided first comparable data 

at a regional level. 

A sample design for the 2003 CAHS covered 

approximately 98% of the Croatian population 

aged 18 and older, due to exclusion of people living 

in non-conventional dwellings, stationed in institutions, 

full-time members of the Croatian Armed 

Forces and residents of some remote regions. 

Observed regions 

The 2003 CAHS used the official definition of 

the five sub-national regions (groupings of counties) 

as proposed by the Central Bureau of Statistics. 

In order to ensure sufficient/representative 

sample for Zagreb (the capital), it was removed 

from the Central region and considered as the 

sixth region for the 2003 CAHS. Using the 2001 

Census of Households, the six main regions were 

further stratified according to the city type (town/ 

municipality) and counties to account for population 

differences. Overall, as the country was 

stratified into 20 design strata a sample of 11,250 

units was required to meet the survey objectives 

219

220 


of providing reliable estimates for six regions and 

taking into account anticipated non-response. For 

the Western region, that included three Counties 

(Primorsko-goranska, Ličko-senjska and Istarska) 

with 565,000 inhabitants, the required sample size 

was 1,645 units. In cooperation with the Croatian 

Central Bureau of Statistics, the 2003 CAHS 

sample of household was selected from the 2001 

Census of Households according to multistage 

stratified cluster design. For the 2003 CAHS, one 

person aged 18 and over per household was randomly 

selected using a simple random sampling 

approach. A structured questionnaire was administrated 

face-to-face to respondents by trained 

public health nurses from the Counties Institutes 

of Public Health in Croatia. The content modules 

of the survey questionnaire were: 1)“household”, 

2) “socio-economic characteristics”, 3) “physical 

measurements, 4) SF-36 (general health, activity 

limitation, mental and physical problems) , 5) 

access to use of health care services, 6) chronic 

conditions, medication, preventive examinations, 

7) smoking (daily smoking, attempts to stop, second 

hand smoking), 8) eating habits, 9) alcohol 

consumption (consumption, binge drinking), and 

10) physical activity (time spent at work and leisure). 

At the end of the interview, anthropometric 

measures such as height, weight, pulse and blood 

pressure were collected from all the respondents. 

The total study sample of 10,766 households 

was selected, and for the Western region the total 

sample was 1,562 households participating in the 

2003 CAHS. The overall response rate was 84-3% 

(9,070 resp. individuals) and for the Western region 

it was 85-6% (1,323 resp. individuals). 

Selected behavioural risk factors 

Behavioural risk factors were observed in relation 

to smoking, high alcohol consumption, inadequate 

nutrition, physical inactivity, elevated blood 

pressure and obesity. For the analysis of data on health 

behaviour, except for smoking, high blood pressure 

and obesity, complex indicators were derived. 

The smoking status of participants was assessed 

on the basis of current daily smoking habit 

and the past habit having existed more than 10 

years ago. 

The prevalence of smoking at the present time 

was recorded. Unhealthy behaviour related to alcohol 

consumption was defined using the WHO 

International Guide for Monitoring Alcohol 

Consumption and Related Harm Recommendations 

(9). The prevalence of heavy drinking was 

defined as drinking 6 or more glasses (regular 

restaurant portions) of alcohol at a single occasion 

at least once a week and he/she was advised 

by somebody (a doctor or health care personnel 

or family member or others) to drink less or 

drinking strong drinks every day whereas somebody 

(a doctor or health care personnel or family 

member or others) advised him/her to drink less. 

Unhealthy nutrition-related behaviour was 

defined as participants satisfying at least three of 

the following five criteria: preparing food using 

animal fat; drinking milk or other dairy products 

with more than 3.2% fat; eating fruit occasionally 

or not at all; eating smoked meat, sausage-meat, 

ham, bacon or similar products every day or almost 

as frequent; add salt to meals almost always 

before even tasting the food. 

Physical inactivity was defined by the respondent 

satisfying at least three of the following 

4 criteria: a respondent goes to work by car, public 

transportation or similar; does not work at all 

or works at home; physically light work (mainly 

walking); doing physical exercise during leisure 

time for at least 30 minutes which makes him/ 

her at least mildly short of breath or perspires not 

more than once a week; doctor or other health 

care personnel or family have had advised him/ 

her to increase physical activity during the last 

year (12 months). 

High blood pressure is a category that included 

people with systolic blood pressure higher 

than 140 mmHg and diastolic blood pressure 

higher than 90 mmHg, and people with diagnosed 

hypertension that is currently under control. 

Obesity is category that included people with 

waist larger than 101 cm for men and larger than 

87 cm for women (10).

Table 1. Estimates of prevalence (per 100 population) of selected behavioral risk factors for cardiovascular diseases in Western 

region of Croatia according to age 

No (%) of examinees according to age groups* 

Behavioral risk factor 

18-34 35-64 65 and older Total (n=1,1323) 

Smoking 225 (17.2) 336 (25.7) 45 (3.4) 606 (46.3) 

High alcohol 8 (0.6) 36 (2.8) 11 (0.8) 55 (4.2) 

Inadequate nutrition 74 (5.6) 86 (6.5) 19 (1.4) 179 (13.5) 

Physical inactivity 62 (4.7) 132 (10.0) 114 (8.6) 308 (23.3) 

High blood pressure 35 (2.7) 227 (20.9) 225 (17.0) 537 (40.6) 

Obesity 56 (4.2) 284 (21.5) 175 (13.2) 515 (38.9) 

* percentages were calculated using the number of valid answers; the percentages of missing data for the whole sample varied between 0% for 

inadequate nutrition, high blood pressure and obesity and 1.1% for smoking 

A respondent without any of the following 

conditions: high blood pressure, elevated blood 

sugar, elevated blood cholesterol, previous myocardial 

infraction or stroke and angina pectoris 

was categorized as Cardiovascular Diseases 

(CVD) not reported. 

Statistical analysis 

Statistical analysis was performed with SPSS 

statistical package for Windows, Version 11.0 

(SPSS Inc., Chicago, IL, USA). Descriptive statistics 

was done using percentages and frequencies. 

The estimates of prevalence for the selected risk 

behaviour were defined for the Western region as 

a whole and then sub-grouped in respect to the 

gender and the age. Variable “age” was divided in 

three age strata: 18-34 years, 35-64 and 65 years 

and older. Overall differences in risk behaviour 


and CVDs were analysed using the chi-square test. 

P-value of 0.01 or less was considered significant. 

RESULTS 

Among the respondents in the Western region, 

there were slightly less males (47.7%) than 

females (52.3%) at the ratio 1:1.1. 

The prevalence of current daily smokers and 

those who quit less than 10 years ago classified 

as smokers in the Western region of Croatia was 

46.3%. More than a quarter of them were at the 

age 35-64 years (Table 1). Nearly every fifth 

smoker (17.2%) was among the youngest age 

group (18-34). Although the prevalence of smoking 

after the age of 64 significantly decreases, 

still 16.9% of older persons were smoking (45 

out of 267 participants who were 65 years and 

older). As for the gender (Table 2), males older 

Table 2. Assessment of differences between examinees according to the age and gender in selected behavioral risk factors for 

cardiovascular diseases in the Western region of Croatia 

Variables in 

the question 

% Gender 

Men Women 

Pearson 

Chi-square 

df 

Statistics* 

p 

Contingency 

Coefficient 

18-34 57.5 65.2 2.289 1 0.130 0.079 

Smoking 

35-64 52.0 47.4 1.413 1 0.235 0.046 

65 and older 28.3 9.4 16.250 1 < 0.001 0.240 

18-34 4.2 0 7.917 1 0.005 0.144 

High alcohol 

35-64 10.5 0.3 34.681 1 < 0.001 0.221 

65 and older 10.5 0 17.275 1 < 0.001 0.248 

18-34 28.6 10.2 20.149 1 < 0.001 0.226 

Inadequate nutrition 35-64 18.5 7.0 20.388 1 < 0.001 0.170 

65 and older 9.4 5.6 1.429 1 0.232 0.073 

18-34 10.6 22.5 9.630 1 < 0.01 0.158 

Physical inactivity 35-64 16.4 22.3 3.783 1 0.052 0.074 

65 and older 38.7 46.0 1.383 1 0.240 0.072 

18-34 13.7 4.8 8.807 1 < 0.01 0.151 

High blood pressure 35-64 46.7 34.8 10.063 1 < 0.01 0.121 

65 and older 84.0 84.5 0.013 1 0.911 0.007 

18-34 13.7 16.1 0.443 1 0.506 0.034 

Obesity 

35-64 31.9 51.2 25.799 1 < 0.001 0.191 

65 and older 53.3 73.8 11.720 1 < 0.01 0.206 

* df, degrees of freedom; p, value of 0.01 or less was considered significant 

221

222 


than 65 consumed significantly (p

dial infarction, stroke, blood pressure higher than 

159/99, waist circumference of more than 101 cm 

for males, and more than 87 cm in females. The 

variable “gender” and risk were found dependent 

(p29,99 

and waist > 101 for man and 87 for woman; § statistically significant, p

224 


and as for the financial status (C=0.208) more 

than two thirds of participants had low income 

(monthly household income in average between 

1000 and 2000 Kunas). 

DISCUSSION 

The prevalence of selected risk factors for 

CVDs in Western Croatia is high as expected. 

Our results support the findings of other authors 

(6, 15-18) that the prevalence of cardiovascular 

risk factors in Croatia is generally high, but that 

their ranking varies on the regions, age and sex. 

Equivalent to Croatian health survey in 2003, 

in neighbouring Slovenia there was a survey 

conducted in 2001 - “Risk Factors for Noncommunicable 

Diseases in Adults in Slovenia” 

(12). Similar findings regarding to age, sex and 

regional differences were found, although with 

some speciality. In Western Croatia smoking was 

found to be the most frequent risk factor in both 

genders. The frequency of daily smokers for the 

Western region in Croatia was higher than that 

found at the national level (6). In general, more 

males than females were cigarette smokers, but 

the difference has been very narrow (18,19). Consuming 

tobacco, especially cigarette smoking, is 

the main avoidable risk factor for CVDs. The total 

of one third of all deaths caused by CVDs can 

be related to smoking cigarettes (20). The risk 

for myocardial infarction increases with age and 

number of cigarettes smoked, so that in middle 

age female who smoke more than 40 cigarettes 

every day, the risk rises for 74.6% (22). 

This problem is more significant due to the 

fact that the habit is mostly present among the 

youngest males and females included in this 

study. Therefore, we conducted the analysis with 

the middle aged respondents (35-64) as more 

prominent for presence of cardiovascular risks 

and related/consequent mortality rates (3). In this 

age group, opposite to prevalent male smokers in 

general, more than a half of the males and two 

thirds of the females are daily smokers or quitted 

less than 10 years ago. So far Croatia has had 

many attempts to promote non smoking on the 

National level. The largest campaign was in 2002 

under the title “Say yes to non smoking”. Unfortunately, 

on a larger scale this action did not last 

long enough to make its impacts durable (23). 

On the other hand, we argue that the absence 

of sensibility for the problem and its true picture, 

lack of financial support and genuine commitment 

on the regional level contribute to continuously 

high level of cigarette smoking. 

High blood pressure followed by obesity was 

present in more than 40 % of participants. We 

found these risks in the middle aged population 

of both genders. Both of these risks are the elements 

of the metabolic syndrome (24). More to 

add, physically inactive was nearly every fourth 

person, especially females of younger ages. Also, 

every seventh person in the Region had inadequate 

nutrition and it can be observed as a special 

risk for males. In younger males, findings 

of inadequate nutrition are more frequent. This 

is an interesting finding in view of the fact that 

the Western region belongs to the Adriatic area 

where Mediterranean food is widely accessible 

and a part of the tradition. (6). 

The frequency of high blood pressure as 

a second risk factor for the Western region in 

Croatia was found little lower than that at the 

national level (5, 6) and the lowest among the 

regions (16). The prevalence of hypertension in 

all regions of Croatia exceeds 50% in males and 

44% in females (6). 

The frequency of obesity as a risk factor 

in Western region of Croatia was higher than 

found at the national level (5, 6). Interestingly, 

the assessment of the results at the national level 

showed that obesity was one of the most common 

risk factor found for females but the least 

prevalent in males (5). Opposite to these findings, 

in the Western region obesity is a seriously 

widespread risk factor for males prior to physical 

inactivity and heavy drinking. 

The occurrence of heavy drinking in the 

Western region in Croatia was found lower than 

that at the national level (6). Stressing the potential 

but insufficient implementation of secondary

prevention and health promotion, high alcohol 

consumers were rarely counselled to reduce or 

stop alcohol use. The importance of heavy drinking 

cessation is in well known relation to cardiovascular 

diseases, but also notably other diseases 

and injuries (25,26). 

To somewhat summarize the occurrence of 

risk factors we may say that in the middle aged 

males, the most prominent risk factor was smoking, 

followed by high blood pressure, obesity, 

inadequate nutrition and physical inactivity. The 

hierarchy was somewhat different in females, 

except smoking which has also been the leading 

risk factor in young females, followed by obesity 

in the middle aged, high blood pressure, physical 

inactivity and inadequate nutrition. 

Can the risk factors for CVD itself, without 

social determinants, correctly assess the situation 

and be used for health care policy recommendation? 

The risk assessment is important but insufficient. 

It would be sufficient if the effects of social 

determinants on appearance and outcome of 

cardiovascular disease were unknown. However, 

the facts and scientific analysis speak precisely 

the opposite (27). Socio-economic status (SES) 

is consistently among the most fundamental determinants 

of health status (28, 29). Furthermore, 

SES relationship can be attributed to CVDs together 

with combined effects of differences in 

health-related behaviours, environmental conditions, 

social structures, and the availability and 

delivery of health care (29). Our findings of low 

education status and low income in relation to high 

risk for CVDs is in agreement with the findings 

REFERENCES 

1. 

2. 

3. 

World Health Organization. European Health for 

all Database (HFA- DB). http:// www.euro.who. 

int/HFADB (5 June 2005). 

Croatian Central Bureau of Statistics, Statistical 

yearbook 2004. Zagreb: Croatian Central Bureau 

of Statistics, 2004. 

Strnad M. Čorić T. Kern J. Polašek O. Mortality 

due to Cardiovascular Diseases. In: Proceedings 

of the Symposium on Regional Distribution 

of Populations Cardiovascular Risk factors in 

Croatia, Zagreb, Croatia, 2nd December, 2005. 

Academy of Medical Science Croatia, Zagreb, 

Croatia, 2005, p.1. 


of other authors (5, 29). They also pinpointed that 

education and income-related disparity influenced 

particularly the tobacco use and diabetes prevalence. 

They occur more among the people with a 

lower SES. The step up in lowering the frequency 

of CVD risk factors, and the concomitant decrease 

in CVD mortality among the adults is a chronic 

disease success story in the United States (29). It 

produced further good news: at least with regard 

to trends in blood pressure and blood cholesterol 

level, people with low annual incomes and low education 

levels were not left behind. These findings 

stress the need for public health efforts in finding 

ways to reach population with lower SES. 

There are some limitations to our study. First, 

study was based on cross-sectional samples, thus 

not designed to assess cause and effect between 

SES and cardiovascular disease risk factors. Our 

goal was not to assess the cause, but to determine 

the population burden of CVD risk factors. Finally, 

our assessment of disease and risk factors 

depended on respondents’ ´ honesty. 

Still, thanks to the CAHS, evidence base for 

CVD prevention programme in Croatia and its 

regions was good, providing a national and regional 

guidance for prevention and health promotion 

in cardiovascular health. It emphasises 

the need for a holistic approach in the promotion 

of healthier lifestyles, especially reducing tobacco 

use and alcohol consumption and promoting 

healthy nutrition and physical activities. 


4. 

5. 


Beland Y, Bailie L, Page J. Statistics Canada, 

Croatian Ministry of Health, and Central Bureau 

of Statistics: a joint effort in implementing 

the 2003 Croatian Adult Health Survey. In: Proceedings 

of the American Statistical Association 

Meeting on survey research methods. Toronto, 

Canada, August 2004. American Statistical Association, 

Toronto, 2004. 

Lukenda J, Kolaric B, Kolčić I, Pažur V, Biloglav 

Z. Cardiovascular diseases in Croatia and other 

transitinal countries: comparative study of publications, 

clinical interventions, and burden of disease. 

Croat Med J 2005; 46:865-74. 

225

226 


6. Kern J, Strnad M, Coric T, Vuletic S. Cardiovascular 

risk factors in Croatia: struggling to provide 

the evidence for developing policy recommendations. 

BMJ 2005; 331:208-10. 

7. Leparski E, Nussel E, eds. Countrywide Integrated 

Non communicable Disease (CINDI) Intervention 

Program. Protocol and guidelines for 

monitoring and evaluation procedures. Berlin: 

Springer-Verlag, 1987. 

8. CINDI 2000. Positioning CINDI to meet the challenges. 

Copenhagen: World Health Organization, 

Regional Office for Europe, 1992. 

9. Ware J. SF-36 Health survey update. Spine 2000; 

25:3130-39. 

10. World Health Organization. International guide 

for monitoring alcohol consumption and related 

harm. Geneva: WHO, Department of Mental 

Health and Substance Dependence, 2000. 

11. Haffner SM, Despres JP, Balkau B, Deanfield JE, 

Barter P, Bassand J-P, Fox K, Van Gaal L, Wittchen 

HU, Tan CE, Smith SC. Waist circumference 

and body mass index are both independently 

associated with cardiovascular disease: The International 

day for the Evaluation of Abdominal 

Obesity (IDEA) survey. J Am Coll Cardiol 2006; 

47 (Suppl A): 842-6. 

12. Zaletel-Kragelj Lj, Eržen I, Fras Z. Interregional 

differences in health in Slovenia II. Estimated 

prevalence of selected behavioral risk Factors for 

cardiovascular and related diseases. Croat Med J 

2004; 45:644-50. 

13. American Heart Association. Heart Disease and 

Stroke Statistics. Dallas: The Association, 2007. 

14. Fowler G. Proven Strategies for smoking cessation. 

Adopting a global approach. Eur J Public 

Health 2000; 10 (Suppl 1):3-4. 

15. Lazarić-Zec D, Dabović-Rac O, Lazičić-Putnik 

Lj. Risk and Protective factors for cardiovascular 

diseases. In: Proceedings of the Symposium on 

Regional Distribution of Populations Cardiovascular 

Risk factors in Croatia, Zagreb, Croatia, 2nd December 2005. Academy of Medical Science 

Croatia, Zagreb, Croatia, p. 21. 

16. Erceg M, Hrabak-Žerjavić V, Ivičević-Uhernik 

A. Croatian Adult Health Survey: High Blood 

Pressure. In: Proceedings of the Symposium on 



Croatia, Zagreb, Croatia, p.2. 

17. Heim I, Kruhek-Leontić D. Obesity and Excessive 

Body Weight in Croatia. In: Proceedings of 

the Symposium on Regional Distribution of Populations 

Cardiovascular Risk factors in Croatia, 

Zagreb, Croatia, 2nd December 2005. Academy 

of Medical Science Croatia, Zagreb, Croatia, p. 

3. 

18. Kovačić L, Gazdek D, Samardžić S. Croatian 

Adult Health Survey: Smoking. In: Proceedings 


of Populations Cardiovascular Risk factors in 

Croatia, Zagreb, Croatia, 2nd December 2005. 


Croatia, p.5. 

19. Vuletic S, Kern J. Croatian Health Survey 2003. 

Hrvatski časopis za javno zdravstvo 2005; 1. [Online] 

http://www.hcjz.hr/clanak.php?id=12389 

(18 December 2007). 

20. Payne WA, Hahn DB. Understanding your health. 

5th ed. Boston: WCB/McGraw-Hill, 1998. 

21. Rumbolt Z. Croatian Adult Health Survey: IN- 

TER-HEART: Global research of coronary risk 

factors. In: Proceedings of the Symposium on 



Croatia, Zagreb, Croatia, pp.13-14. 

22. Center for Disease Control. The health consequences 

of smoking - a report of the surgeon general. 

Atlanta: CDC, 2004. 

23. Marusic A. Croatia opens a national center for the 

prevention of smoking. Lancet 2002; 359:931-54. 

24. Torpy J.M, Lynm C, Glass R.M. The metabolic 

syndrome. JAMA 2006; 295:850. 

25. Mustajbegović J, Doko Jelinić J, Pucarin Cvetkovic 

J, Milošević M, Žuškin E. Croatian Adult 

Health Survey: Alcohol Consuming. In: Proceedings 


of Populations Cardiovascular Risk factors 

in Croatia, Zagreb, Croatia, 2nd December 2005. 


Croatia, p. 6. 

26. Padwal R, Straus S.E, McAlister F.A. Evidence 

based management of hypertension: Cardiovascular 

risk factors and their effects on the decision 

to treat hypertension: evidence based review. 

BMJ 2001; 322:977-80. 

27. Jakšić Ž. Social determinants and cardiovascular 

risk factors. In: Proceedings of the Symposium 

on Regional Distribution of Populations Cardiovascular 

Risk factors in Croatia, Zagreb, Croatia, 

2nd December 2005. Academy of Medical Science 

Croatia, Zagreb, Croatia, p.26. 

28. Davey Smith G, Egger M. Socioeconomic differentials 

in wealth and health. BMJ 1993; 

307:1085-6. 

29. Kanjilal S, Gregg EW, Cheng YJ, Zhang P, Nelson 

DE, Mensah G, Beckles GL. Socioeconomic 

status and trends in disparities in 4 Major risk factors 

for cardiovascular disease among US adults, 

1971-2002. Arch Intern Med 2006; 166:2348-55. 

30. National Institute for statistics. Monthly employee 

salary in average for September 2003. http:// 

www.rif.hr (7 December 2007).


Influence of different glass fiber reinforcements on denture base 

polymer strength (Fiber reinforcements of dental polymer) 

Denis Vojvodić 1 , Dragutin Komar 1 , Zdravko Schauperl 2 , Asja Čelebić 1 , Ketij Mehulić 1 , Domagoj 

Žabarović 1 

1 Department of Prosthetic Dentistry, School of Dental Medicine, 2 Faculty of Mechanical Engineering and Naval Architecture; University 

of Zagreb, Zagreb, Croatia 

Corresponding author 

Denis Vojvodić 

Department of Prosthetic Dentistry, 

Department of Prosthetic Dentistry, 

School of Dental Medicine, 

University of Zagreb, 

Av. G. Šuška 6, 10000 Zagreb, Croatia 

Phone: ++385 1 290 3205; 

Fax: ++385 1 2864 248; 

e-mail: denisvojvodic@yahoo.com 


06 March 2009.; 


20 April 2009.; 

Accepted: 

22 April 2009. 

Med Glas 2009; 6(2): 227-234 

ABSTRACT 

Aim Assessment of flexural strength values of dental base polymers 

reinforced with different glass fibers (“dental” and “industrial” 

origin) after performed artificial ageing procedures. 

Methods Three hundred specimens (dimensions 18 x 10 x 3 mm) 

were produced of denture base polymers reinforced with different 

glass fibers. The “short beam” testing method was used to determine 

the flexural strength of the specimens after polymerization, 

immersion in water of temperature 37 o C for 28 days, and thermocycling. 

Results Flexural strength of the polymer specimens was 91.76- 

122.75 MPa, while specimens reinforced with glass fibers demonstrated 

rise of flexural strength values (103.10-163.88 MPa), no 

matter which type (“dental” or “industrial”) of fibers was used. 

Microscopic examination revealed partial bonding between the 

glass fibers and polymer material. 

Conclusion Both of the investigated glass fibers had similar 

strengthening effect, but due to better investment/benefit ratio “industrial” 

glass fibers could be recommended for dental laboratory 

use. Prolonged polymerization of denture base materials should 

be proposed because it had direct impact on the improvement of 

flexural strength values. 

Key words: dental materials, polymers, glass fibers, dental prosthesis, 

mechanical phenomena 

227

228 


INTRODUCTION 

Life span of the world population has been 

considerably prolonged in the last century because 

of the huge progress of preventive and curative 

medicine. Therefore, the number of elderly people 

(60 and more years old) is increasing. There is also 

evidence of progressive loss of teeth connected 

with the age of patients, and the increased loss of 

teeth is dominant in the population between 50 and 

60 years of age (1). Total loss of teeth is especially 

frequent in patients living in non-developed countries 

due to improper dental care and low health 

education of the population. Dental prostheses are 

at the second place in frequency of different appliances 

that are used by elderly population, just next 

to the glasses (1). Today dental prostheses are predominantly 

made of methyl metacrylate polymer 

which has proven to be the most reliable denture 

base material. Despite many advantages, methyl 

metacrylate is prone to fracturing. Therefore, fractures 

of the dentures are very frequent, almost equal 

to the number of newly made dentures (2). These 

dentures produced from methyl metacrylate may 

be strengthened by incorporation of various reinforcements 

into the denture base polymer, because 

such reinforcements enhance flexural strength and 

resistance to impact (3). Physical and mechanical 

properties of acrylic dentures can be enhanced by 

integration of different fibers with different fiber 

architectures into the denture base polymer (4-9). 

In order to improve flexural and impact strength 

of denture base polymer, graphite (7-11), glass 

(5,6,12-16), and organic fibers, such as, aramide 

(15,17,18) and polyethylene fibers with high molecular 

weight (9,19-27), are used. 

Today the most acceptable fibers for dental 

polymer reinforcements are glass fibers, because 

of their good aesthetics (6,12-14,28,29) and good 

bonding with polymers via silane coupling agents 

(30-32). Also, they can easily be adapted to the 

desired shape and length (33) which is then suitable 

for incorporation into denture base polymer 

material. Different procedures of pre-impregnation 

of glass fiber reinforcements with silane coupling 

agents are used to establish chemical bond 

with denture base polymer material. Glass fiber 

reinforcements produced by dental manufacturers, 

which are present on market, are already pre-impregnated 

with silane coupling agents, but they are 

rather expensive. Common industrial E-glass fibers 

are usually not pre-impregnated during manufacturing. 

They are rather cheap, and it is possible 

to pre-impregnate them with silane coupling 

agents in dental laboratory. 

The main goal of this study was the assessment 

of flexural strength of dental base polymers 

reinforced with silane pre-impregnated glass fibers 

of different architecture produced by dental 

products manufacturers. These results should be 

compared with the results of flexural strength of 

dental base polymers reinforced with “industrial” 

E-glass fibers after they are pre-impregnated in 

dental laboratory using silane coupling agent. 

Obtained results could give the preference of 

which glass fiber reinforcement to use, with regard 

to the investment/benefit ratio. 


Quadratic specimens with smooth surfaces 

and dimensions of 18 x 10 x 3 mm were made of 

Meliodent Heat Cure and Meliodent Rapid (Heraeus 

Kulzer, Hanau, Germany) polymer. Some of 

the specimens made from aforementioned polymers 

were reinforced with glass unidirectional fibers 

and nets produced exclusively for application 

in dentistry (StickTech Ltd., Turku, Finland), and 

some with industrial E-glass unidirectional fibers 

and nets (Kelteks, Duga Resa, Croatia). All the 

specimens were split across ten different groups 

with thirty specimens each (n=300). Special metal 

cuvette was constructed in order to produce uniform 

specimens. It consisted of two thick polished 

metal parts on the sides and two thin metal parts in 

the middle. The middle metal parts had ten quadratic 

perforations of the size of a specimen (18 x 

10 mm). One thin metal part was 1 mm thick and 

the other thin metal part was 2 mm thick. In that 

way the thickness of the specimens and the proper 

glass fiber alignment were obtained. So, the fiber 

reinforcements were placed 1 mm from one side 

and 2 mm from the other side of a specimen. Metal 

parts of the cuvette were smeared twice with Ivo-

clar Separating Fluid (Ivoclar Vivadent, Schaan, 

Liechtenstein). Pre-impregnated glass fibers for 

dental use (StickTech Ltd., Turku, Finland), unidirectional 

(Stick TM ) or net shaped (Stick TM Net) 

were impregnated with Meliodent Heat Cure polymer 

mixture of a syrup consistency (with polymer/monomer 

weight ratio10:8) for eight minutes. 

During impregnation time of the glass fibers Meliodent 

Heat Cure polymer was prepared according 

to the manufacturer’s instructions and placed in 

both cuvette halves (consisting of one thick side 

part + one thin middle part). Just impregnated 

glass fibers, unidirectional (Stick TM ) or net shaped 

(Stick TM Net) were taken from polymer syrup and 

placed on one cuvette half. During that alignment 

procedure unidirectional glass fibers were laid 

along the specimens, in order to be orthogonal to 

the force to be applied. The net shaped glass fibers 

were placed at an angle of 45 o to the length of 

the specimen. The cuvette halves were then closed 

together and put in a hydraulic press (Zlatarne, 

Celje, Slovenia) under the 200 bars pressure. After 

pressing, the cuvette was moved to a manual 

bench vice and put in a polymerizing apparatus 

(Type 5518, KaVo EWL, Biberach, Germany) 

where polymerization was performed according to 

the manufacturer’s instructions. For the specimens 

produced from Meliodent Rapid auto polymerizing 

material a similar procedure was performed. 

The only difference was shorter impregnation time 

of glass fibers (two minutes instead of eight) due 

to the auto polymerizing character of the material. 

Production of the specimens reinforced with 

industrial E-glass fibers was different only in the 

performance of pre-impregnation of the glass fibers 

in dental laboratory. 

Firstly, industrial non-impregnated fibers 

were weighted in weighing-machine Mettler H 

311 (Mettler Instr. AG, Zurich, Switzerland) with 

the accuracy of 0.1 mg, to match the weight of 

dental glass fibers used in equivalent specimens. 

Then, industrial E-glass fibers were cleaned with 

1.6 mol sulphuric acid for 30 sec., rinsed in distilled 

water, and air dried at room temperature for 

24 hours. After that they were dipped into 98% 

γ-metacryloxypropyl-trimethoxysilane (Sigma- 

Vojvodić et al Fiber reinforcements of dental polymer 

Aldrich Co., St. Louis, MO, USA), placed on a 

clean sheet of paper, put in dental sterilizer (ISO 

400, Aesculap, Tuttlingen, Germany) and heated 

at temperature 100 o C for 2 hours. Afterwards, 

these so pre-impregnated glass fibers were impregnated 

with adequate polymer syrup (Meliodent 

Heat Cure or Meliodent Rapid) and the 

specimens were produced in the manner of the 

aforementioned procedures. 

After polymerization of the denture base 

materials and cooling, the cuvettes were opened 

and the specimens were detached. Thin polymer 

excess on all the specimens was removed with a 

carbide bur (Ivomill, Ivoclar Vivadent), and the 

specimen margins were finished using sandpaper 

(Sianor 7/0B, Frauenfeld, Switzerland). The 

specimens were checked with calipers (Dentarium 

042-751, Dentarium, Ispringen, Germany) 

for the accuracy of dimensions, and the maximum 

allowed deviation was 0.05 mm. 

All the specimens were tested in the universal 

testing machine (Amsler, Schafhausen, Switzerland) 

using the short beam method (Figure 1) 

(34), and the moving speed of the blade was set 

to 1.5 mm/min in order to determine the samples’ 

flexural strength. All ten groups of specimens 

were subdivided into three subgroups of ten specimens 

each which were tested after polymerization 

of the specimens, immersion of the specimens in 

distilled water with temperature at 37 o C (thermostat 

Btuj, Poznan, Poland) for 28 days, and after 

thermocycling of the specimens according to 

Hansson’s method (35). Specimens were placed 

in a testing holder, in a position where the fiber 

reinforcements were closer to the testing holder’s 

posts (1mm away from the posts and 2 mm from 

the blade).The force causing breakdown of the 

Figure 1. Scheme of the specimen loading (d, thickness of the 

specimen, F, applied force) 

229

230 


specimens was recorded and the flexural strength 

was calculated according to the formula: 

F max – measured force of the loader (N); l – 

distance between posts (here 15 mm); b – width 

of the specimen (here 10 mm); h – height of the 

specimen (here 3 mm). 

Obtained numerical results were analyzed 

with SPSS statistical package (SPSS Inc., Chicago, 

USA). Statistical analysis was performed 

using descriptive statistics, tests of between-subjects 

effects, Scheffe’s test, and Student’s t-test. 

In order to reveal the quality of bonding between 

glass fibers and denture base polymer, glass 

fiber reinforced specimens were randomly chosen 

and sealed in Durofix material (Struers, Rodovre, 

Denmark). Subsequently they were ground, and 

polished according to the routine procedure (36) to 

obtain a smooth surface suitable for microscopic 

examination. It was performed with the use of a 

light microscope Olympus BH2-UMA (Olympus 

Optical, Tokyo, Japan) and the characteristic images 

were photographed with Olympus C-5050 Ultra 

Zoom camera (Olympus Optical, Tokyo, Japan). 

RESULTS 

During testing specimens made of Meliodent 

Heat Cure and auto polymerizing Meliodent 

Rapid polymer (control groups) demonstrated the 

lowest flexural strength, whereas, the specimens 

reinforced with both types of fibers showed higher 

flexural strength values (Figure 2, Table 1). Scheffe’s 

test applied across ten investigated groups of 

specimens revealed a statistically significant difference 

(P

or “industrial”-Kelteks) had no statistically significant 

influence. That was also confirmed by Student’s 

t-test (t=1.367). Auto polymerizing polymer 

material was weaker than heat-cure polymerizing 

dental base material (P

232 


strength values remained the same or were even 

slightly increased in some of the specimens subgroups 

(Figure 2). Since water absorption that 

occurred during the immersion of specimens in 

distilled water had no negative influence on the 

flexural strength, it could be stated that water absorption 

caused relaxation of the stress in polymer 

material that occurred during polymerization 

shrinkage. That could be the explanation for the 

increase of flexural strength values for the tested 

polymer materials (15,48). 

As mentioned, thermocycling procedure can 

have a significant impact on lowering the mechanical 

properties of polymer materials (46,47). 

On the contrary, in this investigation thermocycling 

procedure increased the flexural strength 

values. It appears as if the increase in temperature 

during thermocycing procedure resulted in 

the effect of prolonged polymerization, which 

could in turn result in the decrease of the residual 

monomer volume thus enhancing the mechanical 

properties of the polymer (increase of the flexural 

strength). Therefore, prolonged polymerization of 

the polymer material should be proposed discarding 

the manufacturer’s instructions on the relatively 

short duration of polymerization, because, 

in the authors’ opinion, it had a direct impact on 

the improvement of mechanical properties. 

Glass fibers, no matter if they were of dental 

or industrial origin, considerably strengthened the 

polymer material, because testing load was shared 

between polymer material and the fiber reinforcements. 

Because of similar strengthening effect, but 

due to relatively high costs of the “dental” glass 

fiber reinforcements, low cost “industrial” glass 

fibers treated with self made pre-impregnation 

could be recommended for dental laboratories. 

Auto polymerizing polymer material was 

significantly weaker than heat-cure polymerizing 

dental base material (P

REFERENCES 

1. Ćatović A, Kraljević K. 

Bolesti usta i zubi. U: 

Duraković Z i sur. Medicina starije dobi. Zagreb: 

Naprijed, 1990:127-33. 

2. Hargraves A. The prevalence of fractured dentures 

Brit Dent J 1969; 20:451-8. 

3. Uzun G, Hersek N, Tincer T. Effect of five woven 

fiber reinforcements on the impact and transverse 

strenght of a denture base resin. J Prosthet Dent 

1999; 81:616-20. 

4. Chong KH, Chai J. Strength and mode of failure 

of unidirectional and bidirectional glass fiberreinforced 

composite materials. Int J Prosthodont 

2003; 16:161-6. 

5. Schreiber CK. The clinical application of carbon 

fibre/polymer denture bases. Br Dent J 1974; 

137:21-2. 

6. Solnit GS. The effect of methyl methacrylate 

reinforcement with silane-treated and untreated 

glass fibers. J Prosthet Dent 1991; 66:310-4. 

7. Schreiber CK. Polymethylmethacrylate reinforced 

with carbon fibres. Br Dent J 1971;130:29-30. 

8. Yazdanie N, Mahood M. Carbon fiber acrylic 

resin composite: an investigation of transverse 

strength. J Prosthet Dent 1985; 54:543-7. 

9. Gutteridge DL. The effect of including ultra-highmodulus 

polyetylene fiber on the impact strength 

of acrylic resin. Br Dent J 1988;164:177-80. 

10. De Boer J, Vermilyea SG, Brady RE. The effect 

of carbon fiber orientation on the fatigue resistance 

and bending properties of two denture resins. 

J Prosthet Dent 1984; 51:119-21. 

11. Ekstrand K, Ruyter IE, Wellendorf H. Carbon/ 

graphite reinforced poly (methyl methacrylate): 

properties under dry and wet conditions. J Biomed 

Mater Res 1987; 21:1065-80. 

12. Vallittu PK. Comparison of the in vitro fatigue 

resistance of na acrylic resin removable partial 

denture reinforced with continuous glass fibers or 

metal wires. J Prosthodont 1996; 5:115-21. 

13. Vallittu PK. Glass fiber reinforcement in repaired 

acrylic resin removable dentures: preliminary results 

of a clinical study. Quintessence Int 1997; 

28:39-44. 

14. Freilich MA, Duncan JP, Meiers JC, Goldberg AJ. 

Preimpregnated, fiber-reinforced prostheses. Part 

I. Basic rationale and complete-coverage and intracoronal 

fixed partial denture designs. Quintessence 

Int 1998; 29:689-96. 

15. Saygili G, Sahmali SM, Demirel F. The Effect of 

placement of glass fibers and aramid fibers on the 

fracture resistance of provisional restorative materials. 

Operat Dent 2003; 28:80-5. 

Vojvodić et al Fiber reinforcements of dental polymer 

16. Vallittu PK. Compositional and weave pattern 

analyses of glass fibers in dental polymer fiber 

composites. J Prosthodont 1998; 7:170-6. 

17. Mullarky RH. Aramid fiber reinforcement of 

acrylic appliances. J Clin Orthod 1985; 19:655-8. 

18. Hull D, Shi YB. Damage mechanism caracterization 

in composite damage tolerance investigation. 

Comp Struct 1993; 23:99-120. 

19. Gutteridge DL. Reinforcement of poly(methyl 

methacrylate) with ultra-high-modulus polyethylene 

fibre. J Dent 1992; 20:50-4. 

20. Ledizesky NH, Ho CF, Chow TW. Reinforcement 

of complete denture bases with continuous high 

performance polyethylene fibres. J Prosthet Dent 

1992; 68:934-9. 

21. Dixon DL, Breeding LC. The transverse strength 

of three denture base resins reinforced with polyethylene 

fibers. J Prosthet Dent 1992; 67:417-9. 

22. Ledizesky NH, Chow TW, Ward IM. The effect of 

highly drawn polyethylene fibres on the mechanical 

properties of denture base resins. Clin Mater 

1990; 6:209-25. 

23. Ledizesky NH, Cheng YY, Chow TW, Ward IM. 

Acrylic resin reinforced with chopped high performance 

polyethylene fiber – properties and denture 

construction. Dent Mater 1993; 9:128-35. 

24. Cheng YY, Hui OL, Ledizesky NH. Processing 

shrinkage of heat-curing acrylic resin reinforced 

with high-performance polyethylene fibres. Biomater 

1993; 14:775-80. 

25. Dixson DL, Ekstrand KG, Breeding LC. The 

transverse strength of three different denture base 

resins. J Prosthet Dent 1991; 66:510-3. 

26. Vallittu PK. Ultra-high-modulus polyethylene 

ribbon as reinforcement for denture polymethyl 

methacrylate. A short communication. Dent 

Mater 1997;13:381-2. 

27. Ramos V, Runyan DA, Christensen LC. The effect 

of plasma-treated polyethylene fiber on the 

fracture strength of polymethyl methacrylate. J 

Prosthet Dent 1996; 76:94-6. 

28. Altieri JV, Burstone CJ, Goldberg AJ, Petel AP. 

Longitudinal clinical evaluation of fiber-reinforced 

composite fixed partial dentures: A pilot 

study. J Prosthet Dent 1994; 71:16-22. 

29. Freilich MA, Karamarker AC, Bustone CJ, 

GOoldberg AJ. Development and clinical applications 

of light-polymerized fiber-reinforced 

composite. J Prosthet Dent 1998; 80:311-8. 

30. Rosen MR. From treating solution to filler surface 

and beyond. The life history of a silane coupling 

agent. J Coat Technol 1978; 50:70-82. 

31. Ellakwa AE, Shortall AC, Marquis PM. Influence 

of fiber type and wetting agent on the flexural 

properties of an indirest fiber reinforced composite. 

J Prosthet Dent 2002; 88:485-90. 

233

234 


32. Soederholm JJ, Shang SW. Molecular orientation 

of silane at the surface of colloidal silica. J Dent 

Res 1993; 72:1050-4. 

33. Finn SR, Springer GS. Delaminations in composite 

plates under transferse static or impact loads 

– A model. Comp Struct 1993; 23:177-90. 

34. Berg CA, Tirosh J, Israeli M. Analysis of short 

beam bending of fiber reinforced composites – 

Testing and design. Philadelphia: American Society 

for Testing and Materials, 1970. 

35. Hansson O. Strength of bond with Comspan 

Opaque to three silicoated alloys and titanium. 

Scand J Dent Res 1990; 98:248-56. 

36. Struers. Preparation of Composites. Rodovre: Struers 

Tech., 1992. 

37. Smith DC. The acrylic denture. Mechanical evaluation, 

mid-line fracture. Br Dent J 1961;110:257- 

67. 

38. Vallittu PK. Fracture surface characteristics of 

demaged acrylic-resin based dentures as analysed 

by SEM-replica technique. J Oral Rehabil 1996; 

23:524-9. 

39. Vallittu PK, Lassila VP, Lappalainen R. Transverse 

strength and fatigue od denture acrylic-glass 

fiber composite. Dent Mater 1994;10:116-21. 

40. Vallittu PK. Flexural properties of acrylic resin 

polymers reinforced with unidirectional and woven 

glass fibers. J Prosthet Dent 1999; 81:318- 

26. 

41. Kanie T, Fuji K, Arikawa H, Inoue K. Flexural 

properties and impact strength of denture base 

polymer reinforced with woven glass fibers. Dent 

Mater 2000; 16:150-8. 

42. Beyli MS, von Fraunhofer JA. An analysis of 

causes of fracture of acrylic resin dentures. J 

Prosthet Dent 1981; 46:238-41. 

43. Vallittu PK, Ruyter EI, Ekstrand K. Effect of water 

storage on the flexural properties of E-glass 

and silica fiber acrylic resin composite. Int J Prosthodont 

1998; 11:340-50. 

44. Vallittu PK. Effect of 180-week water storage 

on flaxural properties of E-glass and silica fiber 

acrylic resin composite. Int J Prosthodont 2000; 

13:334-9. 

45. Craig RG, Powers JM. Restorative dental materials. 

St. Louis, London, Philadelphia, Sydney, Toronto: 

Mosby, 2002. 

46. Oshida Y, Hashem A, Elsalawy R. Some mechanistic 

observation on water-deteriorated dental 

composite resin. Biomed Mater Eng 1995; 5:93- 

115. 

47. Drummond JL, Bapna MS. Static and cyclic loading 

of fiber-reinforced dental resin. Dent Mater 

2003; 19:226-31. 

48. Schneider W, Powers JM, Pierpont HP. Bond 

strength of composites to etched and silicacoated 

porcelan fusing alloys. Dent Mater 1992; 

8:211-5.


Influence of cast surface finishing process on metal-ceramic 

bond strength 

Ketij Mehulić 1 , Martina Lauš-Šošić 2 , Zdravko Schauperl 3 , Denis Vojvodić 1 , Sanja Štefančić 2 

1 2 3 Department of Prosthodontic School of Dental Medicine, University of Zagreb, Dental Polyclinic, Faculty of Mechanical Engineering and 

Naval Architecture, University of Zagreb, Zagreb, Croatia 


Ketij Mehulić, 



Department of Prosthodontic 

Gundulićeva 5, 10 000 Zagreb, 

Croatia 

Phone: ++385 1 4802 112; 

Fax: ++385 1 4802 159; 

e-mail: mehulic@sfzg.hr 


19 March 2009.; 


06 April 2009.; 

Accepted: 

10 April 2009. 

Med Glas 2009; 6(2): 235-242 

ABSTRACT 

Aim To investigate the influence of different cast surface finishing 

process on metal-ceramics bond strength. 

Methods Six Co-Cr alloy sample groups were cast (Wirobond C, 

BEGO, Bremen, Germany) and randomly selected for use in one 

of the six different final processing of the casting surface (oxidation, 

sandblasting with 110 and 250 µm Al 2 O 3 , bonding agent, 

hydrochloric acid solution) prior to application of feldspathic ceramic 

(Duceram Kiss, DeguDent, Hanau-Wolfgang, Germany). 

The testing was carried out with a tensile testing machine (LRX 

with Nexygen software, Lloyd Instr., Fareham, UK) (ISO 9693). 

Results The highest force (66.902 N) for the separation of ceramics 

measured with the sample sandblasted with 250µm Al 2 O 3 , 

oxidised and repeatedly sandblasted with 250 µm, and the lowest 

force (36.260 N) with the sample treated with hydrochloric acid 

solution. With all sample groups except the group with the bonding 

agent (cohesive fracture), an adhesive fracture of the medium 

and an adhesive-cohesive fracture of the peripheral part of the 

fracture surface were observed. The oxidation, prolonged oxidation 

and the bonding agent do not influence the bond strength of 

the tested metal-ceramic system. 

Conclusion Different casting surface treatments have an important 

role on the bond strength of the ceramic-metal interface. 

Key words: casting surface processing, bond strength, metal-ceramic 

restoration, metal-ceramic interface 

235

236 


INTRODUCTION 

Ceramics are being used increasingly as a 

restorative material in a variety of dental restorations, 

including metal-ceramic crowns, all-ceramic 

restorations, and fixed partial dentures, mainly 

as a result of their excellent aesthetic properties, 

durability, biocompatibility and resistance to wear 

(1). Ceramic for dental reconstructive work are 

multiphase silicate ceramics, glass ceramics or 

monophased glasses with varying compositions 

(2,3). Structure composed of ceramic layers on 

a metal frame combined the strength of a metal 

substrate (dental alloy) with aesthetic of a ceramic. 

Currently, these ceramic fused to metal appliances 

are widespread in use in prosthodontics. Because 

of their inherently brittle nature susceptibility to 

their failure was identified at localized areas of high 

stress concentration on the ceramic surface, metalceramic 

interface or within the microstructure (4). 

In any laminate composite system the strength of 

the interfacial bond between the individual laminates 

is a major factor in determining the overall 

resistance of the system to deformation and failure 

(5,6). A strong interface should provide sufficient 

stress transfer between the individual laminates to 

allow the applied loads to be transferred and accommodated. 

Conversely, a weak interface will 

frequently result in failure by a process of delaminating 

under an applied load possibly arising 

from crack initiation and propagation within and 

along the layer (7). These bilayered composites 

have attracted considerable attention from laboratory 

researchers seeking to understand the failure 

characteristics of ceramic fused to metal systems. 

Alterations to the interfacial region between bilayered 

structures are of considerable interest and 

authors have reported the effects of variations in 

the interfacial surface roughness on the mechanical 

properties of metal-ceramics specimens (8). 

By improving a final surface treatment of metal 

substructure could be significantly improved functional 

durability of metal-ceramic appliances. 

Oxidation heat treatment of the metal is used 

to remove the entrapped gas, eliminate surface 

contaminants, and form the metal oxide layer. 

An alloy is deliberately given an oxidation treat- 

ment prior to ceramic application, or whether it 

oxidizes during the portion of the firing cycle 

before flow of the ceramics begins, the fusing ceramics 

comes into immediate contact with oxide 

rather than with metal surface (9,10). Different 

opinions exist as to how this oxide interacts with 

ceramic during the firing cycle. It is widely believed, 

that the fusing ceramic dissolves away the 

oxide originally formed and produces an interaction 

zone responsible for the formation of a bond 

(11). King rejected the oxide layer theories extend 

at that time (Kauzt 1936.) which postulated 

that a layer of oxide adherent to the metal is wetted 

by the ceramics and becomes the transition 

zone between the metal and glassy matrices (12). 

Pask (13) otherwise suggest a direct chemical 

bonding between the ceramic and metal. According 

to Mackert (11) the chromium-containing alloys 

all contain oxygen-active elements: beryl, 

aluminium, vanadium, titanium, and/or yttrium. 

Boron oxide makes these alloys self-fluxing during 

melting and gives them unique melting and 

casting behaviour. The addition of aluminium to 

these alloys adversely affects this behaviour because 

of its tendency to produce slag (14). Because 

of the close correspondence between oxide 

adherence and ceramic bonding, it can only be 

concluded that the adherence of the oxide plays a 

dominant role in ceramic bonding (11). 

The aim of this study was to investigate the 

influence of different cast surface finishing process 

on metal-ceramics bond strength. 

Table 1. Procedures of metal surface treatment for each 

group of samples 

Specimen Metals surface treatment 

1 Sand blasting with 110 μm Al2O3 particles 

2 

3 

4 

Sand blasting with 110 μm Al2O3 particles 

Oxidation 



Oxidation 



Extended oxidation 



Oxidation 

5 


Bonding agent 

6 Etching in acid mixture


Six groups of same three metal cast plates, 

25×3×0.5 mm have been produced according 

to the manufacturer’s instructions. The used alloy 

(Wirobond C, BEGO, Bremen, Germany) 

Mehulić et al Surface finishing and bond strength 

(weight percentage: Cr 26%, Mo 6 %, W 5 %, Si 

1 %, Fe 0.5 %, Ce 0.5 %, C 0.02 %, and the rest 

Co) belongs to the group of cobalt-chrome alloys 

free of the contents of beryllium and nickel. Thus 

produced samples are cleaned and handled in 

same direction, and the surfaces to which ceram- 

Sample 1 Sample 2 



Figure 1. Specimens’ surface of the sample prepared and recorded by a scanning electronic microscope (SEM) with the secondary 

electron detector (SE) (Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Croatia, 2008., with permission) 

237

238 


ics is applied are treated by different procedures 

and combinations of procedures (Table 1). 

Sandblasting was achieved with 110 and 

250 μm Al2O3 particles (Shera, Lemförde, Germany). 

The used bonding agent (3C-Bond, Al- 




Figure 2. Results of 3-point bending test performed on six groups of specimens

phadent N.V., Antwerpen, Belgium) is applied to 

the samples in group 5. The samples of group 6 

are kept in the solution obtained by mixing 50 ml 

of distilled water and 50 ml of 32% hydrochloric 

acid for 30 minutes. After etching these samples 

are first of all washed in distilled water, and then 

in the compound of ethyl alcohol and acetone in 

ratio 1:1. Figure 1 shows the characteristic surface 

of the sample prepared in this way recorded 

by a scanning electronic microscope (Tescan 

Vega TS5136LS, Tescan, Brno, Czech R) with 

the secondary electron detector (SE). 

Along the middle of thus prepared metal 

plates the ceramics (Duceram Kiss, DeguDent, 

Hanau-Wolfgang, Germany) is fired (ceramic 

furnace Focus 2006, Shenpaz, Tel Aviv, Israel) in 

the length of 8 mm, width of 3 mm, and thickness 

of 1 mm. The ceramics corresponds to the manufacturer’s 

instructions and belongs to the group 

of ceramics with the fired temperature of up to 

980°C, suitable for coating of the mentioned alloy. 

The samples are tested by bending in three points 

on the tester machine (LRX Lloyd Instruments, 

Fareham, Great Britain) with installed Nexygen 

programme for the processing of results. The 

samples are set so that the surface with ceramics 

is turned opposite to the pin, and the metal part 

resting on the supports at a distance of 20 mm, 

and the diameter of pin that loads the sample is 1 

mm. The shift of pin is constant during testing at 

a speed of 1.5 mm/min, and the testing continues 

Figure 3. Typical areas during three-point bending test 


until the fracture, i.e. to full separation of the ceramics 

from the metal. 

Testing procedure has been carried out according 

to the guidelines given in ISO 9693 

(15). 

After testing the samples type of fracture surfaces 

(cohesive, adhesive or cohesive-adhesive) 

were examined by scanning electronic microscope 

(Tescan Vega TS5136LS, Tescan, Brno, Czech R). 

The same person has performed all the tests. 

The multiple range tests, Fischer’s LSD test 

and ANOVA have been used for statistic analysis. 

RESULTS 

The results of 3-point bending test performed 

on 6 groups of specimens, (each group has three 

specimens) are presented in Figure 2. 

The diagrams obtained by testing on the tester 

and presented in Figure 2 show the same trend, 

i.e. the behaviour of all samples during testing is 

inter-compatible. Therefore, Figure 3 can generally 

explain the behaviour of all metal-ceramic 

systems in a three-point flexure bond test. 

According to Figure 3 it is possible to define 

three characteristic areas during testing. The 

beginning of testing where the force-deflection 

diagram is a horizontal line, i.e. the pin is lowered 

without increase of force, represents the first 

area. Such behaviour is caused by preparation of 

testing and represents the period from beginning 

of testing to the moment of achieving the predefined 

pre-load. 

Point A (Figure 3), where a sudden increase 

in force is noticed, represents the moment of 

contact between the pin and the sample and the 

actual beginning of the testing area 2. The linear 

part of the diagram that follows from this point 

represents common resistance to flexing of the 

metal-ceramic sample, since in this area the bond 

between metal and ceramics is still strong. 

Point B (Figure 3) represents the start of the 

third area, i.e. the moment of loosening of the bond 

between metal and ceramics and the moment at 

239

240 


which ceramics starts to get separated from metal. 

After point B, there is a short relaxation of the material, 

which is reflected in the decrease of force 

with simultaneous increase of deflection. After 

this relaxation the force-deflection diagram corresponds 

to the diagram for metal alone. 

Based on the performed analysis of the results 

it may be concluded that in order to make 

valid conclusions on the strength of the bond between 

the metal and the ceramics point B is the 

most important one, i.e. force and deflection in 

which the ceramics starts to get separated. Figures 

4 and 5 show the diagrams of these values. 

The method of separation of the ceramic layer 

in the performed tests is almost equal for all the 

groups of samples. The separation always starts at 

the end of the sample and propagates towards the 

middle, which corresponds to the guidelines of 

standard HRN EN ISO 9693. In Figure 4, which 

shows the deflection that has resulted in the separation 

of ceramics from the metal frame, one may 

notice that the mean values of deflection in all 

the samples are approximate and range from 0.07 

mm (sample 6) to 0.17 mm (sample 1). 

Figure 5 shows that the highest mean value 

of force at which ceramics separation was recorded 

in sample 3, whereas the minimal mean 

value of force is recorded in sample 6. The forcedeflection 

diagrams make it possible to quantify 

the difference in the bond strength of the tested 

system based on the additional parameters. 

The analysis of variance has been used to determine 

characteristics of the difference between 

the samples (p < 0.05) for load only, because the 

separation of ceramics in all the samples occurs in 

the approximate amount of deflection. The arithmetic 

means of forces significantly differ among 

individual groups of samples at a risk of 5%. In 

sample 3 the force at which the separation of ceramics 

comes is significantly greater compared 

to other tested samples. In sample 6 the bond between 

ceramics and metal fractures at significantly 

lower forces than in all the other samples. 

Sample 5 treated with bonding agent shows 

on the overall fracture area the presence of a 

layer, which corresponds to the fired agent. The 

value of force necessary to separate the ceramics 

from metal in this sample is not substantially 

different. 

DISCUSSION 

An understanding of the bonding mechanism 

is essential for successful metal-ceramic restorations. 

Although number theories and concepts 

have been proposed for the actual mechanism of 

bonding, it still remains elusive. Different tests 

have been used to determine metal-ceramic bond 

strength and beam failure loads (16). Though it is 

difficult to accurately quantify real bond strength, 

the 3-point flexural test is frequently used. Flexural 

tests were subjected to criticism because maximal 

tensile stresses were created the surface of the ceramics 

and resulted in predictable tensile failures. 

The validity of these tests to evaluate different alloys 

has been questioned because ceramic breakage 

depended on the modulus of elasticity of the 

metal tested. An alloy with an elevated modulus of 

elasticity would resist flexural to a greater extent, 

Figure 4. Deflection values (during a separation of ceramics 

from the metal frame) Figure 5. Load in which ceramics were separated

creating a higher bond (17). It is difficult to quantify 

the real bond strength because in vitro testing 

is not usually in correlation with ceramic breakdown 

in function. The shear strength of the metalceramic 

bond was evaluated by the Shell-Nielsen 

test described by Dent (18) method similar to that 

used by Anthony (19), Moffa (20), Diaz (21), 

Anusavice (22), Warpeha (23), Miller (24), Riley 

(25). The authors suggested that the differences 

in oxide composition and amount, influenced by 

different surface finishing procedures. Sandblasting 

the finished surface is though to remove furrows, 

overlaps, and flakes of metal created by the 

grinding process. A sandblasted surface may have 

higher surface energy that alloys increased wetting 

of the metal during ceramic application. Evidence 

suggested that this roughened surface could also 

provide mechanical interlocking and increase the 

surface area for metal-ceramic bonding (26). According 

to Brantley (27), oxide layer is different 

before and after sandblasting. Graham (28) suggested 

final finishing process in the order: sandblasting, 

grinding, sandblasting and oxidation. 

Smoother surface achieved the lowest values of 

bond strength and bonding agent did not improve 

bond strength because of hermetical sealing of cast 

surface (29). It created alumina layer on cast surface 

and thus change oxide ratio on it (30). The gold 

rich bonding agent reduced the interfacial stress by 

improving the compatibility between ceramic and 

metal (31). Basic elements oxidised selective; and 

created Fe 2 O 3 , In 2 O 3 i SnO 2 on cast surface (32). 

The amount of oxides is not always in proportions 

with elements, which were added. Rake (33) suggested 

opaque in two layers on unutilised surfaces. 

In Ni-Cr alloy (34) and alloy with Pd (35) ceramic 

fired in vacuum produced excessive amount of oxides, 

and argon reduced their appearance. 

REFERENCES 

1. 

2. 

3. 

Mehulić K, Čvrljak Tomić I, Schauperl Z, Komar 

D. Wear Characteristics of Esthetical Prosthetic 

Materials. Acta Stom Croat 2006; 40:56-64 

Mehulić K. Glassceramics. Acta Stom Croat 

2005; 39:477-81. 

Musić S, Živko-Babić J, Mehulić K, Ristić M, 

Popović S, Furić K. Microstructure of leucite 

glass-ceramics for dental use. Materials Letters 

1996; 27:195-9. 


The most reliable evaluation of metal-ceramic 

bond strengths should be based on minimal experimental 

variables and least residual stresses 

at metal-ceramic interfaces. Evaluation for types 

of metal-ceramic failures is critical even though 

cohesive failures within ceramic have been an indication 

of clinically acceptable metal-ceramics 

bond. Although laboratory studies offer predictable 

guidance to comprehensive selection of materials, 

clinical longitudinal studies should also 

be encouraged to complement laboratory results 

and enhance clinical standards (17). 

It can be concluded that the analysis of all the 

parameters used in assessing the strength of the 

bond between metal and ceramics has confirmed 

that the bond is the strongest in the surface treatment 

procedure sandblasting with 250 µm Al 2 O 3 , 

oxidation, and sandblasting again with 250 µm, 

and significantly weaker in the etched sample. It 

should be noted that, in spite of the recommendations 

of the producer of materials and the usual 

practice, the application of the bonding medium 

has not shown any influence on the bonding 

strength of the tested metal-ceramic system. The 

metal samples revealed an adhesive mode of failures 

on the most part of surface, and adhesivecohesive 

on the edges. 

ACKNOWLEDGEMENT 

Grant No. 065-0650446-0435, and No. 120- 

1201767-1762 from the Ministry of Science, 

Education and Sports of the Republic of Croatia 

supported this work. 

4. 

5. 

Competing interests: none declared. 

Fleming GJ, Nolan L, Harris JJ. The in-vitro 

clinical failure of all-ceramic crowns and the connector 

area of fixed partial dentures: the influence 

of interfacial surface roughness. J Dent 2005; 

30:405-12. 

Thomson GA. Influence of relative layer height 

and testing method on the failure mode and origin 

in a bilayered dental ceramic composite. Dent 

Mater 2000;16:235-43. 

241

242 


6. Fleming GJ,El-Lakwah SFA, Harris JJ, Marquis 

PM. The influence of interfacial surface roughness 

on bilayered ceramic specimen performance. 

Dent Mater 2004; 20:142-9. 

7. Ford C, Bush MB, Hu XY, Zhao H. A numerical 

study of fracture mode in contact damage in 

porcelain/Pd-alloy bilayers. Mater Sci Eng 2004; 

202-6. 

8. Milleding P, Wennerberg A, Alaeddin S, Karlson 

S, Simon E. Surface corrosion of dental ceramics 

in vitro. Biomater 1999; 20:733-46. 

9. Camacho GB, Vinha D, Panzeri H, Nonaka T, 

Goncalves M. Surface roughness of a dental ceramic 

after polishing with different vehicles and 

diamond pastes. Braz Dent J 2006; 17:145-9. 

10. Sarac D, Sarac YS, Yuzbasioglu E, Bal S. The effects 

of porcelain polishing systems on the color 

and surface texture of feldspatic porcelain. J Prosthet 

Dent 2006; 96:122-8. 

11. Mackert JR, Parry EE, Hashinger DT, Fairhurst 

CW. Measurement of oxide adherence to PFM alloys. 

J Dent Res 1984; 63:1335-40. 

12. King BW, Tripp HP, Duckworth WH. Nature of 

adherence of porcelain enamels to metals. J Am 

Cer Soc 1959; 42:504-25. 

13. Pask JA, Fulrath RM. Fundamentals of glass to 

metal bonding: Nature of wetting and adherence. 

J Am Cer Soc 1962; 45:592-6. 

14. Ahmad R, Morgano S, Wu BM, Giordano RA. 

An evaluation of the effects of handpiece speed, 

abrasive characteristics, and polishing load on the 

flexural strength of polished ceramics. J Prosthet 

Dent 2005; 94:421-9. 

15. ISO 9693 International Standards fot Dental Ceramics, 

International Organization for Standardization. 

Geneva, Switzerland, 1999. 

16. Papazoglou E, Brantley WA. Porcelain adherence 

vs force to failure for palladium-gallium alloys: 

a critique of metal-ceramic bond testing. Dent 

Mater 1998; 14:112-9. 

17. Hammad IA, Yousef FT. Designs of bond strength 

tests for metal-ceramic complexes: Review of the 

literature. J Prosthet Dent 1996; 75:602-8. 

18. Dent RJ, Preston JD, Moffa JP, Caputo A. Effect 

of oxidation on ceramometal bond strength. J 


19. Anthony DH, Burnett AP, Smith DL, Brooks MS. 

Shear test for measuring bonding in cast gold 

alloy-porcelain composites. J Dent Res 1970; 

49:27-33. 

20. Moffa JP, Lugassy AA, Guckes AS, Gettleman L. 

An evaluation of nonprecious alloys for use with 

porcelain veneers. Part I. Physical properties. J 

Prosthet Dent 1973; 30:424-31. 

21. Diaz-Arnold A, Keller JC, Wightman JP, Williams 

VD. Bond strength and surface characterization 

of a Ni-Cr-Be alloys. Dent Mater 1996; 

12:58-63. 

22. Anusavice KJ. Phillips` science of dental materials. 

10th ed. Philadelphia: WB Saunders; 1996. 

pp. 655-720. 

23. 23.Warpeha WS Jr, Goodkind RJ. Design and 

technique variables affecting fracture resistance 

of metal-ceramic restorations. J Prosthet Dent 

1976; 35:291-8. 

24. Miller LL. Framework design in ceramo-metal 

restorations. Dent Cl N Am 1977; 21:699-716. 

25. Riley EJ. Ceramo-metal restoration. State of the 

science. Dent Cl N Am 1977; 21:669-82. 

26. Hofstede TM, Ercoli C, Graser GN, Tallents RH, 

Moss ME, Zero DT. Influence of metal surface 

finishing on porcelain porosity and beam failure 

loads at the metal-ceramic interface. J Prosthet 

Dent 2000; 84:309-17. 

27. Brantley WA, Cai Z, Papazoglou E, Mitchell JC, 

Kerber SJ,.Mann GP, Barr TL. X-ray diffraction 

studies of oxidized high-palladium alloys. Dent 

Mater 1996;12:333-41. 

28. Graham JD, Johnson A, Wildgoose DG, Shareef 

MY, Cannavina G. The effect of surface treatments 

on the bond strength of a nonprecious 

alloy-ceramic interface. In J Prosthodont 1999; 

12:330-4. 

29. Al Mutawa NJ, Sato T, Shiozawa I, Hasegawa S, 

Miura H. A study of the bond strength and color 

of ultralow-fusing porcelain. In J Prosthodon. 

2000; 13:159-65. 

30. McLean JW. The search for improved metal-ceramics. 

Quint Dental Technol 1978;2:51-9. 

31. Wu Y, Moser JB, Jameson LM, Malone WF. The 

effect of oxidation heat treatment on porcelain 

bond strength in selected base metal alloys. J 

Prosthet Dent 1991; 66:439-44. 

32. Miyagawa Y. X-ray difraction at the metal-ceramic 

interface. Surface oxides of 88% Au alloys containing 

Fe, In, Sn for porcelain fusing, Sh Rikog 

Zass 1978; 19:15-27. 

33. Rake PC, Goodacre CJ, Moore BK, Munoz 

CA. Effect of two opaquing techniques and two 

metal surface conditions on metal-ceramic bond 

strength. J Prosthet Dent 1995; 74:8-17. 

34. Pask JA, Tomisia AP. Oxidation and ceramic 

coatings on 80Ni20Cr alloys. J Dent Res 1988; 

9:1164-71. 

35. Wagner WC, Asgar K, Bigelow WC, Flinn RA. 

Effect of interfacial variables on metal-porcelain 

bonding. J Biomed Mater Res. 1993; 27:531-7.


Use of digital photography in the reconstruction of the occlusal 

plane orientation 

Nikola Petričević 1 , Marko Guberina 2 , Robert Ćelić 1 , Ketij Mehulić 1 , Marko Krajnović 2 , Robert Antonić 3 , 

Josipa Borčić 4 , Asja Čelebić 1 

1 2 3 Department of Prosthodontics, School of Dental Medicine, University of Zagreb, Zagreb, Private Dental Practice, Zagreb, Department 

of Prosthodontics, School of Dental Medicine, University of Rijeka, Rijeka, 4Department of Oral and Maxilofacial Surgery, School of 

Dental Medicine, University of Rijeka, Rijeka; Croatia 


Nikola Petričević, 

Department of Removable 

Prosthodontics, 


University of Zagreb 

Gundulićeva 5, 10000 Zagreb, Croatia 

Phone. ++ 385 1 4802 165; 

Fax.: ++385 1 4802 159; 

E-mail: petricevic@sfzg.hr 


13 September 2008; 


11 December 2008; 

Accepted: 

12 January 2008. 

Med Glas 2009; 6(2): 243-248 

ABSTRACT 

Aim This study evaluated whether the occlusal plane measurements 

on digital photographs were reliable for the reconstruction 

of occlusal plane. 

Methods Forty-two subjects (25 female and 17 male subjects, 

aged 19 to 30 years) with all teeth and Angle Class I participated. 

Irreversible hydrocolloid impressions were made and the casts 

were poured in dental stone (ISO Type I) and finally mounted in 

the S.A.M. 2 “P”, articulator (S.A.M. Praezisiontechnik, GmbH, 

Munich, Germany) by a quick mount face-bow transfer. Lateral 

digital photographs were taken from a distance of 1.5 m in a natural 

head position with a subject in erect posture. A Fox plane was 

placed over the maxillary dental arch. A quick-mounting face-bow 

was positioned. The angles between the articulator horizontal 

plane and the occlusal plane (AHP-OP), as well as those between 

the face bow and the Fox plane (FB-FP) were measured, and the 

significance of the difference between the means was tested by the 

t-test (p

244 


INTRODUCTION 

Correct occlusal plane orientation in prosthodontic 

reconstructive treatments is one of the most 

important factors for the stability of the removable 

dentures and for the achievement of good 

esthetics, phonetic and masticatory function, as 

well as for the patient’s satisfaction (1-8). 

A faulty orientation of occlusal plane will 

jeopardize the interaction between the tongue 

and the buccinator muscle. Where the occlusal 

plane is too high, the tongue cannot rest on the 

lingual cusps of the mandibular denture teeth and 

prevent its displacement. There is also a tendency 

for accumulation of the food in the buccal and 

lingual sulci (4). An occlusal plane that is too 

low could lead to the tongue and cheek biting 

(9). When the occlusal plane orientation is lost 

by complete or partial edentulism, it should be 

relocated correctly by means of a prosthodontic 

restoration. Over the last century, investigators 

have used various methods and advocated many 

anatomical landmarks to set a correct occlusal 

plane orientation and position to be able to set 

artificial denture teeth appropriately (1-5, 9-26). 

A record of the occlusal plane orientation of 

an individual with natural teeth should be helpful 

in any reconstructive treatment. Therefore, the 

position of the occlusal plane in both, fixed and 

removable denture wearers could be as close as 

possible to the position which was previously occupied 

by the occlusal plane of the natural teeth. 

This also enables better denture stability and decreases 

patients’ adaptation to dentures (27-29). 

Recent developments of digital photography 

and wide use of personal computers have 

made these techniques and equipment widely 

available. Photographic analysis of craniofacial 

characteristics has already been used in dentistry, 

mainly in orthodontics, and it is considered to be 

acceptably reproducible (30-35). 

The aim of this study was to check the reliability 

of measurements on the digital photographs 

for possible reconstruction of occlusal 

plane in the future. 


Forty two subjects (25 female and 17 male 

subjects, aged between 19 and 30 years, average 

24 years) were selected from dental students at 

the University of Zagreb, Croatia, according to 

the following eligibility criteria: complete natural 

dentition (except for occasionally missing 

third molars) and normal occlusion (bilateral Angle 

Class I molar and canine relation). 

All subjects were well-informed and gave a 

written consent to participate in the study. The 

study was approved by the Institutional Ethics 

Committee. 

Irreversible hydrocolloid impressions of the 

maxillary and mandibular jaw were made (Alginoplast 

fast set, Heraeus Kulzer, Hanau, Germany) 

and the casts were poured in dental stone 

(ISO Type I, Vel-Mix Stone, Kerr Italia S. p. A., 

Salerno, Italy). The casts were mounted in the 

S.A.M. 2 “P” articulator (S.A.M. Praezisiontechnik, 

GmbH, Munich, Germany) through a transfer 

with a quick-mounting face-bow. 

Prior to measurement a transparent triangular 

plate was placed over the maxillary teeth, so that 

the contacts of cusps of the maxillary posterior 

teeth with a transparent triangular plate could be 

observed. Most often, the first posterior contact 

was between the triangular plate and the mesiopalatal 

cusp of the first molar. In 3 subjects the 

first posterior contact was between the triangular 

plate and the premolar palatal cusp. 

The occlusal plane was defined on the cast 

of the maxillary jaw as the plane connecting the 

incisal edge of the maxillary central incisors and 

the mesiopalatal cusp of the left maxillary first 

molar (or the first cusp of the posterior teeth in 

contact with a transparent triangular plate placed 

over the maxillary teeth). 

The following was measured: the vertical 

distance between the incisal edge of the maxillary 

central left incisor and the articulator horizontal 

plane, the vertical distance between the 

mesiopalatal cusp of the first left maxillary molar 

(or the first cusp of the posterior teeth in contact

with a transparent triangular plate) and the articulator 

horizontal plane, as well as the horizontal 

distance between the incisal edge of the left maxillary 

central incisor and the mesiopalatal cusp of 

the first left molar (or the first cusp of the posterior 

teeth in contact with a transparent triangular 

plate). 

Measurements were made with a calliper of 

0.1 mm precision (MEBA, Zagreb, Croatia). Values 

obtained were transferred to a sheet of paper, 

calibrated in millimeters, and the lines were 

drawn. The occlusal plane was drawn and the angle 

(AHP-OP angle) between the horizontal line 

(representing articulator horizontal plane) (AHP) 

and the occlusal plane (OP) (representing the distance 

between the left maxillary central incisor 

and the first lateral cusp in contact with a transparent 

triangular plate, mostly mesiopalatal cusp 

of the first maxillary molar) was measured to the 

nearest 0.5 degree mark. 

Lateral digital photographs of each subject 

were obtained in accordance with the following 

procedure: A quick-mounting face bow of the 

S.A.M. articulator was placed on the subject’s 

face; olives (plastic auriculars) were gently introduced 

into the meatus accousticus externus 

and the arch was fixed on the soft nasion. The 

Fox plane (Candulor AG, Wangen, Switzerland) 

was also placed in the mouth (Fig. 1). The subjects 

were standing barefoot on the ground in 

front of a mirror, with his/her feet slightly apart 

and divergent externally, and both arms hanging 

loosely. Following that, the subject was asked 

to look straight into the mirror (1.5 m x 0.5 m) 

at the reflection of his/her pupils and to assume 

a relaxed and normal erect posture of the head 

and shoulders. This is considered to be a natural 

head position (NHP) (22, 23). The mirror was 

positioned 1.5 m away, in front of the subject. All 

digital photographs were taken from a distance 

of 1.5 m with the subject standing, clenching the 

Fox plane and with the facial arch positioned. 

Digital photographs were obtained by using 

a digital camera (Fuji Finepix A310, 3.1 Megapixel 

3x Optical/2.9x Digital Zoom) on an adjustable 

tripod (Manfrotto Tripod Digi MN714- 

Petričević et al Occlusal plane and digital photography 

SHB) conveniently adjusted so that the camera 

was at the height of the subject’s ala-tragus line. 

The images were transferred by an USB cable to 

a personal computer in JPEG format. 

The ISSA computer program was used for 

direct measurements on the screen (VAMS, Zagreb, 

Croatia): the grid-lines were drawn by superimposing 

the Fox plane (FP) and the face-bow 

plane (FB); and the angle between FP and FB 

planes was measured (FB-FP angle). 

Statistical analysis included testing the normality 

of distribution by the one sample Kolmogorov-Smirnov 

test and descriptive statistics. 

The significance of the differences between males 

and females was assessed by the independent Student’s 

t test. The significance of the differences 

between the occlusal plane inclination measured 

in the articulator and on the digital photographs 

was tested by the Student’s t test for dependent 

samples. The significance was set at 95% probability 

level. 

RESULTS 

The data was distributed normally, as revealed 

by the one-way Kolmogorov-Smirnov 

test (p>0.05). Therefore, parametric tests were 

used for further statistic analysis. There was no 

significant difference between men and women 

(for AHP-OP angle: t = 0.81, d.f. = 40, p = 0.412; 

for FB-FP angle: t = 1.16, d.f. = 40, p = 0.23), as 

revealed by the independent Student’s t test. 

Descriptive data (x ± SD) is shown in the 

Table 1. 

There was no significant difference between 

the articulator AHP-OP angle (angle between the 

articulator horizontal plane and the maxillary 

Table 1. Angle between the horizontal plane and the occlusal 

plane* 

Angle x SD No 

AHP-OP 8.56 3.1 42 

FB-FP 8.80 4.2 42 

*AHP-OP, angle measured after mounting in the articulator; FB-FP, 

angle measured on digital photographs; x, mean; SD, standard deviation; 

No, number of measurements 

245

246 


occlusal plane), and the digital photograph FB- 

FL angle (between the Fox plane and the quickmounting 

face bow plane) (p>0.05) (Table 2). 

DISCUSSION 

One of the major problems in prosthodontics 

therapy is the lack of reproducible referencestructures 

for determining orientation and position 

of the occlusal plane. Not only did different 

authors use different landmarks and methods to 

establish the occlusal plane, but also the definition 

of the occlusal plane varied throughout the literature 

(1-5, 9-26). Although almost all textbooks on 

prosthodontics advocate the orientation of the occlusal 

plane parallel to the Camper’s line, many 

authors found significant differences between the 

orientation of the natural occlusal plane and the 

ala-tragus line (4,11,13,18,22,26,31). Another 

widely used landmark for the establishment of 

the artificial occlusal plane is the retromolar pad, 

although it was found out that orientation upon 

retromolar pad could place the occlusal plane a 

little too low posteriorly from the natural occlusal 

plane (3,20). Nissan (4) concluded that the 

cephalometric analysis alone cannot determine 

the location of the occlusal plane in edentulous 

patients and, consequently, he advocated that intraoral 

structures, which had been described by 

other authors should be considered (2,3,14). Bassi 

concluded that the cephalometric parameters 

do not correspond to the clinical positioning of 

the posterior teeth in a successful rehabilitation 

with complete denture (21). 

Although many articles in the literature describe 

the establishment of the occlusal plane in 

completely or partially edentulous patients, none 

of the described methods seem to be completely 

satisfactory. Much of the controversy results 

from the small number of subjects examined, 

Table 2. Significance of the differences between AHP-OP and 

FB-FP angle* 

x diff t df p 

AHP-OP:FB-FP -0.242 -0.253 41 0.81 (>0.05, N.S.) 

*AHP-OP, measured on casts mounted in the articulator; FB-FP, 

measured on digital photographs; x diff, mean difference between 

angles; t, t-value; df, degree of freedom; p, p-value 

great variability of the location of anatomical 

structures and the lack of an agreement on the 

definition of the exact anatomical structures. 

In order not to change proprioceptive regulatory 

mechanisms which ensure normal function 

of the cheek, tongue and other masticatory muscles, 

establishment of the occlusal plane should 

be reconstructed as close as possible to the position 

prior to the loss of teeth,. Therefore, a record 

of the patient’s occlusal plane orientation would 

be helpful in a reconstructive therapy. Recent development 

of digital photography and wide use 

of personal computers and their low cost have 

made these techniques and equipment widely 

available. 

Therefore, this study was made with the idea 

that general practitioners can easily obtain the 

profile digital photographs of their patients with 

a Fox plane in the mouth (representing the occlusal 

plane). Such photographs could be used for 

measurement of the occlusal plane inclination in 

a possible reconstructive treatment. Photographic 

evaluation of craniofacial characteristics has been 

already purposefully used in orthodontics and 

other fields of dentistry, and has showed to be acceptably 

reproducible in earlier studies (30-35). 

The method of digital photography used in 

this study has already been standardized (8, 30- 

35) and has proved to be reproducible and reliable 

(26, 20-35), which is in agreement with the 

results of this study. We placed a Fox plane and 

a facial arch on the face of each subject in order 

to obtain objective data and information valuable 

for a clinical practice. Great advantage of digital 

photography in comparison with the cephalometric 

analysis is that it avoids exposition of subjects 

to potentially harmful radiation and it was therefore 

used in the present study. 

The results of this study revealed no significant 

differences between genders (P>0.05) for 

the angle between the articulator horizontal plane 

and the occlusal plane (for both measurements), 

which is in agreement with other similar studies 

(3,13,17,19,30). 

In order to test the accuracy of the inclina

Figure 1. Subject with a quick-mounting face bow and Fox 

plane positioned (left profile) (N. Petričević, 2008., with 

patient’s permission) 

tion of the occlusal plane on digital photographs, 

the AHP-OP angle (between the articulator horizontal 

plane and occlusal plane) and FB-FP angle 

(face-bow-Fox plane on digital photographs) 

were measured, and the significance of the differences 

between them was tested by using the 

Student’s t test for dependent samples. The mean 

difference between the angles was only 0.242 

degrees, which is of no clinical relevance. However, 

there was no significant difference between 

the angles measured on the articulator and on the 

digital photographs (Table 1 and Table 2). This 

study confirms the hypothesis that digital photographs 

are reliable for craniometric analysis. It 

REFERENCES 

1. 

2. 

3. 

4. 

Carey PD. Occlusal plane orientation and masticatory 

performance of complete dentures. J Prosthet 

Dent 1978; 39:368-71. 

Alfano SG, Leupold RJ. Using the neutral zone 

to obtain maxillomandibular relationship records 

for complete denture patients. J Prosthet Dent 

2001; 85:621-3. 

Celebic A, Valentic-Peruzovic M, Kraljevic K, 

Brkic H. A study of the occlusal plane orientation 

by intra-oral method (retromolar pad). J Oral 

Rehabil 1995; 22:233-6. 

Nissan J, Barnea E, Zeltzer C, Cardash HS. Relationship 

between occlusal plane determinants 

and craniofacial structures. J Oral Rehabil 2003; 

30:587-91. 

Petričević et al Occlusal plane and digital photography 

also proves that digital photographs with a subject 

biting on the Fox plane could be helpful in 

any possible future reconstructive prosthodontics 

procedures where the occlusal plane must be reestablished. 

ACKNOWLEDGEMENTS/DISCLOSURE 

This study was partly presented as a part of: 

Petričević N., Čelebić A., Poljak-Guberina R., 

Knezović Zlatarić D., Komar D. Accuracy of digital 

photograph measurements in reconstruction 

of occlusal plane orientation. Proceeding of the 

12 th Meeting of International College of Prosthodontics, 

Fukuoka, Japan, September 5, 2007. 

The authors wish to acknowledge the support 

of the Ministry of Science, Education and 

Sports of the Republic of Croatia, Project No. 

065-0650446-0420: Influence of Prosthetic Therapy 

and Other Factors to Orofacial System and 

Health (original title: Utjecaj protetskog rada i 

drugih faktora na stomatognati sustav i zdravlje) 

and Project No. 062-0650446-0499: Stess, occlusal 

trauma and oral-surgical patology (original 

title: Stres, okluzijska trauma i oralno-kirurška 

patologija). 

Subject on the Figure 1 was well-informed 

and gave a written consent to publish photograph 

of his face in this journal. 

5. 

6. 

7. 

8. 


Williams DR. Occlusal plane orientation in 

complete denture construction. J Dent 1982; 

10:311-6. 

Celebic A, Knezovic-Zlataric D. A comparison 

of patient’s satisfaction between complete and 

partial removable denture wearers. J Dent 2003; 

31:445-51. 

Celebic A, Knezovic Zlataric D, Papic M, Carek 

V, Baucic I, Stipetic J. Factors related to patient 

satisfaction with complete denture therapy. J Gerontol 

A Biol Sci Med Sci 2003; 58:M948-53. 

Wright, C.R. Evaluation of the factors necessary 

to develop stability in mandibular dentures. J 

Prosthet Dent 2004; 92:509-18. 

247

248 


9. Monteith, B.D. A cephalometric method to determine 

the angulation of the occlusal plane in edentulous 

patients. J Prosthet Dent 1985; 54:81-7. 

10. Foley PF, Latta GH. A study of the parotid papilla 

relative to the occlusal plane. J Prosthet Dent 

1985; 53:124-6. 

11. Guillen GE, Staffanou RS. Occlusal plane modification 

of an existing maxillary complete denture 

prior to removable partial denture construction: a 

case report. Quintessence Int 1991; 22:543-6. 

12. Van Niekerk, FW, Miller VJ, Bibby RE. The alatragus 

line in complete denture prosthodontics. J 


13. Karkazis HC, Polyzois GL. Cephalometrically 

predicted occlusal plane: Implications in removable 

prosthodontics. J Prosthet Dent 1991; 65:258- 

64. 

14. Rich H. Evaluation and registration of the H.I.P. 

plane of occlusion. Aust Dent J 1982; 27: 162-8. 

15. Sloane RH, Cook J. A guide to orientation of the 

occlusal plane. J Prosthet Dent. 1953; 3:53 

16. Celebic A, Brkic H, Kaic Z, Vojvodic D, Poje Z, 

Singer Z. Occlusal plane Orientation in Klinefelter 

Syndrome (47, XXY males). J Oral Rehabil 

1997; 24:942-6. 

17. Vojvodic D, Celebic A, Valentic-Peruzovic M, 

Cifrek M, Kraljevic K, Stipetic J. A study of the occlusal 

plane orientation by extraoral method (Camper’s 

line). Coll Antropol 1996; 20 (Suppl.):109-13. 

18. Koller MM, Merlini L, Spandre G, Palla S. A 

comparative study of two methods for the orientation 

of the occlusal plane and the determination of 

the vertical dimension of occlusion in edentulous 

patients. J Oral Rehabil 1992; 19:413-25. 

19. Karkazis HC, Polyzois GL. A study of the occlusal 

plane orientation in complete denture construction. 

J Oral Rehabil 1987; 14:399-404. 

20. Ismail YH, Bowman JF. Position of the occlusal 

plane in natural and artificial teeth. J Prosthet 

Dent 1968; 20:407-11. 

21. Bassi F, Deregibus A, Previgliano V, Bracco P, 

Preti G. Evaluation of the utility of cephalometric 

parameters in constructing complete denture. Part 

I: placement of posterior teeth. J Oral Rehabil 

2001; 28:234-8. 

22. Petričević N, Stipetić J, Antonić R, Borčić J, 

Strujić M, Kovačić I, Čelebić A. Relations between 

Anterior permanent teeth, dental arches and 

hard palate. Coll Antropol 2008; 32:1099-1104. 

23. Rener-Sitar K, Petričević N, Čelebić A, Marion 

Lj. Psychometric properties of Croatian and 

Slovenian short form of oral health impact profile 

questionnaires. Croat Med J 2008; 49:536-44. 

24. Petričević N, Čelebić A, Ibrahimagić-Šeper L, 

Kovačić I. Appropriate proportions as guidelines 

in selection of anterior denture teeth. Med Glas 

2008; 5: 103-8. 

25. Ibrahimagić-Šeper L, Čelebić A, Petričević N, 

Selimović E. Anthropometric differences between 

males and females in face dimensions and 

dimensions of central maxillary incisors. Med 

Glas 2006; 3:58-62. 

26. Petricevic N, Celebic A, Celic R, Baucic-Bozic M. 

Natural head position and inclination of craniofacial 

planes. Int J Prosthodont 2006; 19:279-80. 

27. Celebic A, Valentic-Peruzovic M, Alajbeg ZI, 

Mehulic K, Knezovic Zlataric D. Jaw elevator silent 

periods in complete denture wearers and dentate 

individuals. J Electromyogr Kinesiol 2008; 

18:947-54. 

28. Celebic A, Alajbeg ZI, Kraljevic-Simunkovic S, 

Valentic-Peruzovic M. Influence of different condylar 

and incisal guidance ratios to the activity of 

anterior and posterior temporal muscle. Arch Oral 

Biol 2007; 52:142-8. 

29. Alajbeg IZ, Valentic-Peruzovic M, Alajbeg I, Illes 

D, Celebic A. The influence of dental status on 

masticatory muscle activity in elderly patients. Int 

J Prosthodont 2005; 18:333-338. 

30. Ciancaglini R, Colombo-Bolla G, Gherlone EF, 

Radelli G. Orientation of craniofacial planes and 

temporomandibular disorder in young adults with 

normal occlusion. J Oral Rehabil 2003; 30:878- 

86. 

31. Ferrario VF, Sforza C, Serrao G, Ciusa V. A direct 

in vivo measurement of the three-dimensional 

orientation of the occlusal plane and of the sagittal 

discrepancy of the jaws. Clin Orthod Res 

2000; 3:15-22. 

32. Ferrario VF, Sforza C, Miani A, Tartaglia G. 

Craniofacial morphometry by photographic evaluations. 

Am J Orthod Dentofacial Orthop 1993; 

103:327-37. 

33. Ferrario VF, Sforza C, Germano D, Dalloca LL, 

Miani A. Head posture and cephalometric analyses: 

an integrated photographic / radiographic 

technique. Am J Orthod Dentofacial Orthop 

1994; 106:257-64. 

34. Chiu CS, Clark RK. Reproducibility of natural 

head position. J Dent 1991; 19: 130-1. 

35. Celebic A, Stipetic J, Nola P, Petricevic N, Papic 

M. Use of digital photographs for artificial tooth 

selection. Coll Antropol 2004; 28:857-63.


A three-dimensional evaluation of microleakage of the class V 

cavities restored with flowables 

Paris Simeon 1 , Silvana Jukić-Krmek 1 , Goranka Prpić-Mehičić 1 , Ivica Smojver 2 , Ivica Anić 1 , Ivica Pelivan 3 

1 2 School of Dental Medicine, University of Zagreb, Department of Endodontics and Restorative Dentistry, Faculty of Mechanical Engeneering 

and Naval Architecture, 3School of Dental Medicine, University of Zagreb, Department of Prosthodontics; Zagreb, Croatia 


Paris Simeon 



Department of endodontics and 

restorative dentistry, 

Gundulićeva 5, 10 000 Zagreb, Croatia 

Phone: +385 1 4802 126; 

Fax: +385 1 4802 159 

E-mail: paris.simeon@zg.t-com.hr 


16 March 2009; 


05 May 2009; 

Accepted: 

06 May 2009. 

Med Glas 2009; 6(2): 249-255 

ABSTRACT 

Aim To evaluate the dye leakage of three flowables with a new 

‘’three dimensional’’ method. 

Methods Three groups of twelve premolars have received Class 

V cavities of uniform standardized dimensions. The cavities were 

restored with: Clearfil liner Bond 2 with adhesive SE Bond (group 

I), Definite flow with Etch & Prime 3.0 (group II) and, the Tetric 

flow with Syntac Single Component (group III). The teeth were 

immersed in a contrast dye for 24 hours, rinsed and immersed in 

the 5% nitric acid for 72 hours. The teeth were acid-softened and 

the fillings were pulled out of their cavities. The inner surfaces of 

extracted fillings were photographed in three different rotated positions 

(3 x 120 o ). The photographs were transferred to a computer 

image and the deepest point and the area of the leaked surface 

were determined. 

Results All restorative systems showed leakage at the adhesive 

level. The statistical analysis showed significant differences between 

group I and group III in the number of leaked samples, in 

the depth of leakage and in the leaked surface. Best results in all 

three ways of leakage evaluation were obtained in group I (Clearfil 

liner Bond 2 with adhesive SE Bond). 

Conclusion In this study, flowable Clearfil liner Bond 2 with adhesive 

SE Bond had leaked in all three ways of evaluation significantlly 

less than Tetric flow in combination with Syntac Single 

Component. 

Key words: microleakage, dye leakage, class V restorations, flowable 

resins 

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INTRODUCTION 

Restorative materials and procedures often 

fail to produce an intact marginal integrity (1). 

The cervical region cavities are burdened with a 

highly stressful position and with a non-homogenous 

tooth structure (2). The cervical cavities 

have also a stressful cavity configuration and are 

usually restored with resin restoratives which 

exhibit shrinkage during polymerization causing 

failures (3). Marginal gaps between restoratives 

and the cavity walls are a consequence of such 

a failure, thus causing leakage (4). Nonetheless 

the properties of flowable composites make them 

suitable as a restorative material for this highly 

stressful region (5,6). 

The researches of marginal leakage usually 

describe a two-dimensional, linear and very unclear 

pattern of microleakage (7). Dye leakage is 

the oldest and most common method of detecting 

a leakage in vitro. The main disadvantages of this 

method are its qualitative nature and the fact that 

damage to the sample occurs due to sectioning, 

eventually leading to false results (8,9). The ideal 

way of understanding would be if we could somehow 

extract the filling undamaged from its cavity 

and see the leakage in its full physical appearance. 

The aim of this study was to investigate and 

evaluate the leakage of three flowables with a 

new ‘’three dimensional’’ method which enables 

the extraction of the filling out of the cavity and 

the direct measurement of the died surface and 

maximum depth of the leakage. Thus the dye 

leakage becomes a fully quantitative method. 


Thirty-six intact premolars, extracted for orthodontic 

reasons were randomly divided in three 

groups of twelve each. All teeth have received 

buccal cervical Class V cavities of uniform standardized 

dimensions (3 x 2 x 1.5 mm) with margins 

in enamel and cementum. These cavities were 

prepared with a diamond-coated bur (# 811 031 

4,2ML, Diatech – SDI, Switzerland) mounted on 

a water-cooled air-driven handpiece. The specific 

shape of the bur enabled easy, almost automatic, 

preparation of the cavity simply by pressing the 

rotating bur at the previously determined cervical 

buccal position of each tooth. The same bur was 

used for 12 cavities and replaced with a new one. 

Following the preparation prior to the restoration 

groups 1 and 2 required no additional etching because 

of the self-etching primer included in their 

adhesive systems. Cavities of the group 3 were 

additionally etched for 20 seconds with 37% ortophosphoric 

acid. All cervical cavities were restored 

according to the manufacturer’s instructions. Restorative 

material used in this research consisted 

of three groups of adhesive restorative systems 

produced by three different manufacturers. Each 

group was restored with the - respectively - sameproducer 

flowable restorative and same-producer 

adhesive system, as follows: 

Group I SE Bond (Lot.41116) and Clearfil 

liner Bond 2 (Lot 0045A) (Kuraray, 

Osaka, Japan); 

Group II Etch & Prime 3.0 (Lot. 22005C) and 

Definite flow (Lot.12003B) (Degussa, 

Hanau, Germany); 

Group III Syntac Single Component (Lot 

D33562) and Tetric flow (Lot. 

E38161) (Vivadent, Schaan, Liechtenstein). 

The cavities were restored in one single injected 

layer of flowable composite and subsequently 

polymerized for 40 seconds all with the 

same-type Elipar II (ESPE, Germany) halogen 

light device. All restorations were finished and 

polished. 

The specimens were then thermally cycled 

for 1000 cycles in cold (5 o C) and warm (55 o C) 

baths with dwell times of 60 s and the transfer 

time of 10 s. After thermocycling, the root surfaces 

and the adjacent enamel were coated with 

two layers of nail varnish, except the filling surface 

and the area 1 mm around the filling. The 

specimens were then immersed in a contrast liquid 

(acid resistant - Rotring Ink, Stanford GmbH, 

Hamburg, Germany) for 24 hours, rinsed with tap 

water, and immersed in 5% nitric acid. After 72

hours the teeth were softened enough to pull the 

fillings out from their cavities with ease, just with 

a sharp excavator. The extracted fillings have 

thus become the specimen ready for observation. 

Leakage pattern was observed and measured 

through a dissecting microscope equipped with 

a digital camera (Olympus SZX-12 and Olympus 

DP-12, Olympus Optical Co.GmbH, Hamburg, 

Germany). Photographic images of the inner surface 

(tooth-faced) of the specimens were taken 

in three different positions, the different position 

meaning a one-third rotation (for 120 o ) in order 

to encompass the entire filling mantle (360 o ). The 

photographs were then transformed into computer 

images. A CAD (computer-aided design) 

computer program was used to observe the leakage 

pattern and to measure died surfaces. 

The first method of assessment was to measure 

the maximum depth point of leakage, and ordinal 

rating scores or levels - ranging from 0 to 

3 - were attributed to the marginal dye leakage. 

The ordinal rating scores are defined as follows 

(Figure 1): 

Figure 1. The scheme of a specimen with marked levels (in 

order to measure the point of leakage) (P. Simeon, 2005.) 

score 0 – no leakage; score I – leakage deep 

up to 1/3 of internal surface (up to 0.71 mm); 

score II – leakage deep up to 2/3 of internal surface 

(up to 1.42 mm); score III – leakage deep 

through entire lateral surface and filling’s bottom 

(up to 2.14 mm). 

Simeon et al Three-dimensional evaluation of microleakage 

The second method of leakage evaluation was 

to measure the inner surface of the filling colored 

with the contrast dye on three different surfaces of 

each specimen. The colored surface was measured 

in mm² and the total inner surface of (specimen’s) 

filling’s mantle was totaling 15.1 mm². 

For the statistical analysis of the depth of 

microleakage the highest (maximal) result measured 

in one specimen was used. For the analysis 

of surface of microleakage the sum of the leaked 

area from all three differently angled images was 

calculated. As a post-hoc test Kruskal-Wallis 

with Mann-Whitney U tests were used. 

RESULTS 

The observation showed that all restorative 

systems had leaked at the adhesive level, e.g. 

between the restorative material and the walls of 

the prepared cavity (Figure 2). The values of the 

deepest point and the area of leakage of all tested 

samples and materials are shown in Table 1. 

In Group I only one (1) restoration (8%) had 

leaked, in Group II four (4 viz. 33%) restorations, 

and in Group III seven (7 viz. 58%) restorations 

Figure 2. Filling from the Group II specimen No 3, with dye 

leakage in surface 1 and level of depth 2. Arrows are pointing 

the area of marginal leakage and the triangle is pointing the 

maximal depth of leakage. The blue and red marks are the 

orientation marks. (P. Simeon, 2005.) 

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252 


out of total of 12 respectively. Comparing the frequency 

of leaked samples, a statistically significant 

difference was found between Group I and 

Group III (χ 2 = 6.75; df = 1; p = 0.009). 

Considering the area of the leaked surface, a 

statistically significant difference was found between 

the groups (χ 2 = 6.34; df = 2; p = 0.042). 

The Mann-Whitney test showed a significant difference 

between Group I and Group III (U = 3; 

Z = 2.58; p = 0.010). The ranking of the groups 

according the mean range of the Kruskal Wallis 

test showed the best range of the Group I (s.r. = 

13.88), then Group II (s.r. = 18.67) and, as the 

last, the range Group III (s.r = 22.96). This means 

that Group III had a larger area of the leaked surface 

than Group I, but it could not be said of the 

leaked area of Group II to be larger than Group I 

or smaller than Group III. 

Comparing the three groups of material 

according to the deepest point of leakage, the 

Kruskal Wallis test showed a difference between 

the groups (χ 2 = 5.99; df = 2; p = 0.050). The 

Mann-Whitney test showed the statistically significant 

difference between group I and III (U = 

36.5; Z = 2.44; p = 0.015). The differences between 

Group I and Group II, and Group II and 

Group III were not statistically significant. The 

ranking of groups according to the mean range 

of the Kruskal Wallis test showed the best range 

of the Group I (s.r. = 14.04), then Group II (s.r. = 

18.58) and, as the last, Group III (s.r = 22.88). 

DISCUSSION 

Adhesive restorative dentistry today has not 

- in the clinical environment - accomplished its 

goal i.e. the optimal adhesion that would totally 

endure the stress forces generated in the cervical 

area of the tooth (8,9). The capability of the 

restorative materials to seal the restoration borders 

is influenced by the resin composition and 

the filler, the material’s plastic deformability and 

ability to flow, the thermal expansion coefficient, 

the Young modulus, the choice of the enameldentin 

adhesive system and restorative technique 

used, the mechanical stress due to the cavity 

shape (8), and eventually the quality of the hard 

dental tissue (8,9). 

Table 1. Microleakage of flowable restorative materials according the leaked surface and deepest point of leakage for each specimen 

that expressed leakage 

Flowable restorative 

material 

Specimen that 

leaked 

Leaked surface (mm2) 

Surface 1 Surface 2 Surface 3 

Total leaked 

surface 

(mm2) 

Deepest point of leakage (mm) 

Surface 1 Surface 2 Surface 3 

Group I 

Spec. 

No. 1 

0.36 0.36 

*1.22 - 

Level 2 

Spec. 

No. 2 

0.09 0.09 

*0.44 - 

Level 1 

Spec. 

No. 3 

0.38 3.89 0.54 4.81 

1.32 – 

Level 2 

*2.14 – 

Level 3 

1.33 – 

Level 2 

Group II 

Spec. 

No. 6 

3.66 1.29 4.95 

*1.78 – 

Level 3 

1.61 – 

Level 3 

Spec. 

No. 7 

0.09 0.09 

*0.62 – 

Level 1 

Spec. 

No. 1 

0.08 0.08 

*0.20 – 

Level 1 

Spec. 

No. 2 

0.23 0.23 

*0.81 – 

Level 1 

Spec. 

No. 3 

0.38 0.38 

*0.92 – 

Level 2 

Spec. 

No. 4 

0.89 0.89 

*1.10 – 

Level 2 

Group III 

Spec. 

No. 5 

1.06 1.06 

1.25 – 

Level 2 

Spec. 

No. 6 

1.05 0.19 0.47 1.71 

*1.76 – 

Level 3 

1.14 – 

Level 2 

1.16 – 

Level 2 

Spec. 

No. 7 

0.70 0.70 

*2.14 – 

Level 3 

*the maximal depth of microleakage used for statistical analysis

The flowable composite, because of its injectability 

in the cavity, surpasses one of composite’s 

clinically less practical characteristics 

(stickiness for example) (10,11). It is a kind of 

material capable of flowing like honey with a 

lower Young modulus (11) which combines the 

good characteristics of the hybrid composites and 

their applicability (10). The material is therefore 

recommended for Class V restorations (12,13). 

The reason for this recommendation in the toothneck 

area is the non-directional loading of the occlusal 

and articulation forces. On the other hand, 

the cervical area is highly burdened depending 

on the stressed cavity configuration and the flexional 

forces (because of the tooth deflection). It 

is indicated because of its favorable mechanical 

properties of the flowables during and after the 

polymerization process (lower modulus, lower 

rigidity of the hardened material). The material’s 

property to flow during the pre-gel phase reduces 

the overall tension on the hybrid layer, on the polymerized 

material itself, and finally on the cavity 

walls. 

The leakage of oral fluid, together with 

bacteria and their by-products, happens in the 

majority of the present-day restorations (7,14) 

regardless of their adhesive mediators. The microleakage 

comprehension and its evaluation is 

important because of the ability of the process 

itself to weaken and - finally - get the restoration 

lost during its clinical lifetime. 

The microleakage and nanoleakage research 

more or less objectively confirm the presence of 

a leakage but do not show how severe the leakage 

is influencing the final evaluation of a certain 

restorative system or material (8,15). A great 

part of laboratory researches objectively observe 

and prove the leakage by a contrast-fluid penetration 

(4,13). The “reading” of the leakage is a 

two-dimensional process based on the fact that a 

specimen is mostly sectioned or broken, or prepared 

to obtain several cuts thru the cavity and 

restoration surface, in order to see and measure 

the leakage. However, it is not objective, no matter 

how precisely it is done. The specimen used 

in a three-dimensional method of research (8,9) 


shows higher a quality of evaluation of the microleakage 

thru the tissue-restoration margins 

bond. This method enables the «reading» of the 

leakage of the contrast dye through marginal microcraks. 

Of course, there is a certain danger of 

non-objectivity in the use of the mentioned twodimensional 

procedure and the fact that a partial 

picture of the leakage is taken as the measure of 

the evaluation of a restorative material and therefore 

conclusions of this kind could be misleading 

for a reader. 

Further, the observation and measurement 

of microleakage routinely requires a dissecting 

microscope with a mounted digital camera (13). 

The leakage is measured in two ways: a maximum 

depth point of leakage with the associated 

rating scores or levels, ranging from 0 to 3, and 

the other way is to measure the surfaces colored 

with the contrast dye leak. An alternative could 

be to measure the concentration of the contrast 

dye with a spectrophotometer (4) or a similar 

device. This data is to be statistically analyzed 

and qualified conclusions to be drawn. All of the 

aforementioned researches are similar for the 

most part in their respective procedures. In order 

to evaluate leakage a most objective method is 

needed. One part of this mosaic is surely the need 

to understand the problem of the marginal cracks. 

The essential defining characteristics of the threedimensional 

method is to bring the elevated and 

more realistic value of the results because of the 

possibility to observe the leakage rather clearly, 

and because of the combination of two methods 

of evaluation and subsequent quantification 

of the leakage. The pattern of microleakage according 

to the research could be superficial with 

only slight marginal coloring. But this slight superficial 

marginal coloring could penetrate from 

this margin into the deep dentinal surfaces near 

the pulp with all consequences (8). This understanding 

of different patterns of leakage justifies 

the use of the two different methods of leakagemeasurement, 

in order to find the most objective 

way to evaluate the quality of a certain material. If 

we were to apply only one of the aforementioned 

methods, for example, a small edge-superficial 

leakage could mean only a small irrelevant dam- 

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254 


age to a restoration. On the other hand, it could 

mean a deep thin highway straight down into the 

pulp. So clarified a picture of leakage enables in 

vitro research making better use of the contrast 

dye which could leave better traces on the inner 

surface of the restoration investigated by making 

it easier to observe and “read”. Improvement 

could be achieved by a better observation of the 

aforementioned leaked surfaces (a digital threedimensional 

scanner instead of a three-angled 

digital photography of each filling) and subsequent 

transfer of the data to a computer, in order 

to get a best-quality computer-image of the innerrestoration 

surfaces. 

The results of this research are hardly comparable 

to other related researches because of the 

difference in the methods applied. The analysis 

of the results of this study, according to the dual 

criteria, showed that statistically-significant better 

flowable-restoratives were Clearfil liner and 

ormocer Definite flow. Between these two flowables 

there were no statistically significant differences, 

although the former had showed a lesser 

leakage, the least of all. The question is how a 

resin flowable material indicated to be a lining 

material would eventually behave as a definitive 

restorative material in terms of its physical and 

mechanical properties. That is the reason why we 

give the advantage to the Definite flow ormocer 

REFERENCES 

1. 

2. 

3. 

4. 

5. 

Irie M, Suzuki K, Watts DC. Marginal gap formation 

of light activated restorative materials: effects 

of immediate shrinkage and bond strength. 

Dent Mater 2002; 18:203-10. 

Retief DH. Do adhesives prevent microleakage? 

Int Dent J 1994; 44:19-26. 

Van Meerbeek B, Braem M, Lambrechts P, Vanherle 

G. Evaluation of two dentin adhesives in 

cervical lesions. J Prosthet Dent 1993; 70:308- 

14. 

Aguiar FHB, Ajudarte KF, Lovandino JR. Effect 

of light curing modes and filling techniques on 

microleakage of posterior resin composite restorations. 

Oper Dent 2002; 27:557-62. 

Wattanawongpitak N, Yoshikawa T, Burrow MF, 

Tagami J. The effect of bonding system and composite 

type on adaptation of different C-factor 

restorations. Dent Mater J 2006; 25:45-50. 

definitive flowable resin. Significantly less successful 

was Tetric flow restorative in comparison 

to the Clearfil liner, but not when compared 

with the ormocer Definite flow. Regardless of 

the method of research, our results are similar to 

those of other related research investigating the 

resin composites (16,17) attributing good properties 

to the composites, but different from the results 

of those research where other materials had 

been more successful (18). According to Eliades 

(19) the clinical relevance of the formulation 

and testing of the dentine bonding systems is not 

clear and not always comparable to the clinical 

situation, but certainly significant and necessary 

as a part of the mosaic of evaluation and recommendation 

of restorative systems, and therefore 

a good indicator for the convenience of both the 

manufacturers and clinicians (7,14,19, 20). The 

quality-marks of different restoratives are vital in 

the clinical restorative dentistry and are the results 

of both in vitro and in vivo researches and the data 

so obtained. According to this, and by the rules 

prescribed by various dental associations (ADA, 

IADR, CRA), a clear picture of a given restorative 

is made. More research is needed to better illustrate 

the marginal leakage and to give an evaluation 

of the investigated flowable restoratives. 

ACKNOWLEDGEMENTS/DISCLOSURE 


6. De Boever JA, Mc Gall WD, Holden S, Ash MM. 

Functional occlusal forces: An investigation by 

telemetry. J Prosthet Dent 1987; 40:326-33. 

7. Rueggeberg FA. Substrate for adhesion testing 

to tooth structure - Review of the literature. Dent 

Mater 1991; 7:2-10. 

8. De Munck J, Van Landuyt, Peumans M, Poitevin 

A, Lambrechts P, Braem M, Van Meerbeek 

B.A critical review of the durability of adhesion 

to tooth tissue: Methods and results. J Dent Res 

2005; 84:118-32. 

9. Hilton TJ. Can modern restorative procedures 

andmaterial reliably seal cavities? In vitro investigations. 

Part 2. Am J Dent 2002; 15: 279-89. 

10. Bayne SC, Thompson JY, Swift EJ, Stamatiades 

P, Wilkerson M. A characterization of first generation 

flowable composites. J Am Dent Assoc 

1998; 129:567-77.

11. Chuang SF, Liu JK, Jin YT. Microleakage and 

internal voids in class II composite restorations 

with flowable composite linings. Oper Dent 2001; 

26:193-200. 

12. Frankenberger R, Lopes M, Perdigao J, Ambrose 

WW, Rosa BT. The use of flowable composites as 

filled adhesives. Dent Mater 2002; 18:227-38. 

13. Yazici AR, Baseren M, Dayangac B. The effect 

of flowable resin composite on microleakage in 

class V cavities. Oper Dent 2003; 28:42-6. 

14. Pashley DH, Sano H, Ciucchi B, Yoshiyama M, 

Carvalho RM. Adhesion testing of dentin bonding 

agents: A review. Dent Mater 1995; 11:117-25. 

15. Silveira de Araujo C, Incerti da Silva T, Ogliari 

FA, Meireles SS, Piva E, Demarco FF. Microleakage 

of seven adhesive systems in enamel and 

dentin. J Contem Dent Pract 2006; 7:26-33. 

16. Ernst CP, Cortain G, Spohn M, Rippin G, Willerhausen 

B. Marginal integrity of different resin 

based composites for posterior teeth: an in vitro 

dye penetration study on eight resin composite 

and compomer adhesive combinations with a particular 

look at the additional use of flow composites. 

Dent Mater 2002; 18:351-8. 


17. Jang KT, Chung DH, Shin D, Garcia-Godoy F. 

Effect of eccentric load cycling on microleakage 

of class V flowable and packable composite resin 

restorations. Oper Dent 2001; 26:603-8. 

18. Schneider BT, Baumann MA, Watanabe LG, 

Marshall GW. Dentin shear bond strength of 

compomers and composites. Dent Mater 2000; 

16:15-9. 

19. Eliades G. Clinical relevance of the formulation 

and testing of dentine bonding systems. J Dent 

1994; 22:73-81. 

20. Folwaczny M, Mehl A, Kunzelmann KH, Hickel 

R. Clinical performance of a resin modified glass 

ionomer and a compomer in restoring non carious 

cervical lesions –five year results. Am J Dent 

2001; 13:153-6. 

255

256 


Oral health of the Croatian army recruits in 2001 

Tomislav Badel 1 , Jadranka Keros 2 , Vjekoslav Jerolimov 1 , Nikša Dulčić 1 , Snježana Restek Despotušić 3 

¹Department of Prosthodontics, 2Department of Dental Anthropology; School of Dental Medicine, University of Zagreb, Zagreb, 3Dental Office, Barracks “Ban Krsto Frankopan”, Koprivnica; Croatia 


Tomislav Badel, 

Department of Prosthodontics, 


University of Zagreb 

Gundulićeva 5, 10000 Zagreb, Croatia 

Phone: +385 1 48 02 125, 

Fax: +385 1 48 02 159 

E-mail: badel@sfzg.hr 


16 July 2008; 


12 December 2008; 

Accepted: 

03 March 2009. 

Med Glas 2009; 6(2): 256-260 

ABSTRACT 

Aim Oral health of Croatian Army recruits has been researched. In 

2001, 505 19-year-old recruits in the barracks in Koprivnica were 

clinically examined and asked about their health care habits. 

Methods The oral status of all teeth (except wisdom teeth) was 

described by the DMFT index (decayed, missing, and filled teeth) 

and compared with the FST index (filled and sound teeth). The 

level of the recruits’ restored teeth was calculated by the formula 

FTx100/DFT. 

Results The research showed the average DMFT index value of 

7.32. The average value of the FST index was 23.56, and 47.8% 

of the teeth were restored. A statistically significant difference according 

to domicile was determined in the DT, MT, FT and FST 

index. The subjects from rural environments had more teeth affected 

by caries, and those from urban environments had more restored 

teeth (66.59%). The health condition of the subjects from 

urban environments is better (higher values of the FT index and 

slower cumulative distribution and statistical significance of the 

FST index). 

Conclusion The FST index is more adequate than the DMFT index 

for application in populations with a higher level of teeth affected 

by caries. The research conducted contributes to the determination 

of dental health of the Croatian Army recruits as well as to the 

organisation of optimal preventive programs. 

Key words: dental caries, recruits, DMFT, epidemiology

INTRODUCTION 

Oral health assessment is based on the examination 

of incidence and frequency of dental 

caries. Its spread is determined by regional factors 

and dynamic migration of people and it is directly 

determined by nutrition, oral hygiene and 

type of fluoridation. Epidemiological studies of 

caries use methodological standards, especially 

the decayed, missing, and filled teeth (DMFT) 

index as an indicator of the cumulative effect of 

caries on permanent teeth during life. The data 

about smaller and specific groups are especially 

important, due to the interaction of various socioeconomic 

states and habits (1, 2). 

The system of health protection oriented towards 

planning and implementation of preventive 

measures against caries brought about the tendency 

of decline in caries prevalence in children and 

adolescents in all European countries (2-5). 

Oral health of recruits was a subject of many 

epidemiological studies carried out in Australia (6, 

7), the Czech Republic (8), Denmark (9), Germany 

(10, 11), Italy (12), Norway (13), Switzerland (14, 

15), UK (16), Turkey (17), and Croatia (18, 19). 

The purpose of our study was to assess oral 

health of Croatian army recruits by establishing 

the DMFT value depending on age and social 

communities the subjects came from. 


Caries prevalence was examined in the Dental 

Clinic of the Recruits Centre in Koprivnica. 

The study was carried out in 2001 and comprised 

505 randomly chosen recruits at the age of 19. 

The subjects were classified according to their 

area of living (urban and rural). 

Caries was diagnosed by standard instruments, 

diagnostic light and Kuhhorn probe. Caries 

was described by the DMFT index as follows: 

D=decayed, M=missing, F=filled and T=teeth. 

Teeth with diagnosed decay (D) were classified 

in D 2–4 according to Marthaler (20). This clinical 

classification includes caries lesions with cavitations 

that can be identified by probing. Initial le- 

Badel et al Oral health of the army recruits 

sions were not considered. The level of restored 

teeth was calculated by the formula FTx100/DFT. 

Wisdom teeth were not examined, and the study 

also comprised subjects without caries (DMFT=0). 

The FST index (F=filled and S=sound teeth). 

Clinical examination included the evaluation 

of dental status and was performed always in the 

same way, starting from the lower right quadrant. 

The data on potential risk factors for caries were 

entered in a form made for this purpose, containing 

the living areas, and oral and hygienic habits 

of the subjects (number of toothbrushing per day 

and reasons to visit the dentist per year). No radiographs 

were taken. 

Multi-examiner training, calibration and 

validation courses were arranged by two independent 

examining teams, each consisting of a 

dentist and a dental nurse. Dental examinations 

were carried out by the authors of this study, who 

were calibrated between themselves by asking 

each other to examine the same group of recruits 

and to compare the findings. 

The statistical analysis (average, standard 

deviation, t-test, chi-square tests, one phase variance 

analysis) was performed by means of the 

programme STATISTICA for Windows, Release 

5.5 A (‘99 Edition). Statistical significance of 

p

258 


Table 2. Test differences of the DMFT index and FST index in subgroups of the subjects (average and standard deviations for caries 

frequency) by means of variance analysis* 

Subgroups No of subjects DMFT DT MT FT FST 

Total 505 7.32±4.85 3.15±3.23 1.29±1.90 2.88±3.55 23.56±4.13 

Urban 160 7.64±4.66 1.28±3.02 0.93±1.49 4.43±3.74 24.79±3.51 

Rural 345 7.18±4.94 3.56±3.25 1.45±2.04 2.17±3.23 22.99±4.28 

Probability statistical test 0.158

DISCUSSION 

Croatia is a country with characteristics of a 

socio-economic transition. The DMFT index is a 

good indicator of the degree of development and 

an important factor in designing and planning the 

national programmes of oral health starting from 

the earliest age (4). 

The data about the DMFT values in populations 

of recruits are relatively numerous. Morgan 

et al. (6) determined the DMFT values of 6.8 in 

Australian Navy recruits. In subjects of Australian 

army recruits Hopcraft and Morgan (7) determined 

a decline in the level of caries experience, with 

the mean DMFT scores for recruits aged between 

17-35 was 6.08. For the subjects of the same age 

(17-25 years of age) in this study DMFT scores 

were only 4.11. Krejsa et al. (8) established the 

average DMFT value of 6.22 (DT: 0.87, MT: 0.02 

and FT: 5.33) in 18-year-old Czech recruits. Antoft 

et al. (9) found a decrease of caries of 63% in 

Danish recruits in the period between 1972-1993 

(DMFT 6.2. in 1993), Willerhausen et al. (10) 

found the average DMFT index of 13.0 in German 

recruits, and Klimek et al. (11) the value of 

7.5. In Italian recruits the determined DMFT was 

7.14 (12). Asmyhr et al. (13) revealed caries decrease 

in Norwegian recruits to the DMFT value 

of 10.2. In the study of Swiss recruits Menghini et 

al. (14) established the DMFT values of 10.1 (DT: 

4.2, MT: 0.5 and FT: 5.4), and in 1996 Menghini 

et al. (15) found a decline in caries of 48%, which 

amounted to 5.06. In Royal Air Force recruits Richardson 

and McIntyre (16) revealed a caries decrease 

to DMFT 6.5. A study of Turkish recruits 

(17) established the DMFT values of 6, with a 

significant relationship between the DMFT value 

and sugar consumption. A common characteristic 

of all results in these studies is significant caries 

decrease in recruits, and the determined DMFT 

Badel et al Oral health of the army recruits 

values which are mostly lower than those determined 

in our study of the Croatian army recruits. 

Specific characteristics of various age and 

social populations in Croatia with respect to age 

and social status are discussed in many studies. In 

the former Yugoslavia there were great differences 

between caries prevalence between the developed 

and undeveloped Federal Republics. The average 

DMFT value for 12-year-olds amounted to 6.1 and 

for 18-year-olds as high as 10.9 (21). The spread of 

caries was exceptionally wide, and therefore, the 

DMFT index for the age range between 19 and 29 

amounted between 10.18 and 12.48 (22). Lobnik- 

Gomilšek (23) found the average DMFT index of 

8.06 for military recruits in the Federal Republics 

of the former Yugoslavia (for the subjects from 

rural areas 7.64 and urban areas 8.52). In Croatia 

the average DMFT value was 8.41 (DT: 3.87, MT: 

1.15 and FT: 3.39), with a higher value in urban 

areas. According to our results for Croatian recruits, 

a decline in caries of 7.7% was found. In 

the analysis of single values share of DMFT it can 

be concluded that there is a decline of decayed 

teeth for 48%, whereas there is an increase of filled 

teeth for 25%. An increase in the number of missing 

teeth for 30% is unfavourable. Previous studies 

of Croatian recruits showed that the most common 

oral disease was dental caries (value 5.84), 

and in 2000 healthy teeth were found in only 4% 

subjects, but with better values of the investigated 

indices. The DMFT=6 value was lower, and the 

FST=25 value was higher (18, 19). 

Epidemiological studies provide valuable data 

on the health status of groups of inhabitants, assessing 

the prophylactic measures that have been implemented. 

They also provide guidelines for improvement 

of oral health, which is especially important in 

European countries in transition (24-26). 

Table 3. Test differences of the DMFT index and FST index in subgroups of the subjects according to the number of toothbrushing 

per day (average and standard deviations for frequency) by means of variance analysis* 

Subgroups No of subjects DMFT DT MT FT FST 

1 time per day 264 7.25±4.84 3.54±3.30 1.28±1.99 2.43±3.26 23.18±4.30 

2 times per day 214 7.50±4.94 2.84±3.16 1.34±1.84 3.32±3.75 23.82±3.97 

3 times per day 27 6.67±4.35 1.89±2.52 0.93±1.30 3.85±4.15 25.19±3.16 

Probability statistical test 0.659 =0.007 =0.571 =0.008 =0.026 

*DMTF, Decayed, Missing, Filled, Teeth; DT, Decayed, Teeth; MT, Missing, Teeth; FST, Filled and Sound Teeth 

259

260 


ACKNOWLEDGMENT / DISCLOSURE 

This study is a part of the scientific project 

No. 065-0650445-0441 supported by the Ministry 

of Science, Education and Sports, the Republic 

of Croatia. 

The manuscript was presented as a part of: 

Badel T, Restek-Despotušić S, Keros J, Azinović 

REFERENCES 

1. Thylstrup A, Fejerskov O. Textbook of clinical 

cariology. Copenhagen: Munksgaard, 1999. 

2. Freire MC, Sheiham A, Netuveli G. Relationship 

between height and dental caries in adolescents. 

Caries Res 2008; 42:134-40. 

3. Petersson HG, Bratthall D. The caries decline: A review 

of reviews. Eur J Oral Sci 1996; 104:436-43. 

4. Marthaler TM. Changes in dental caries 1953– 

2003. Caries Res 2004; 38:173-81. 

5. Reich E. Trends in caries and periodontal health 

epidemiology in Europe. Int Dent J 2001; 51: 

392-8. 

6. Morgan MV, Stonnill A, Laslett AM. Dental 

caries amongst Royal Australian Navy recruits, 

1988. Aust Dent J 1992; 37: 201-4. 

7. Hopcraft M, Morgan M. Dental caries experience 

in a young adult military population. Aust Dent J 

2003; 48: 125-9. 

8. Krejsa O, Mrklas L, Broukal Z. Caries of 18-yearold 

recruits in the Czech Republic in 1995 [Abstract]. 

Caries Res 1996; 30:302. 

9. Antoft P, Rambusch E, Antoft B, Christensen HW. 

Caries experience, dental health behaviour and 

social status-three comparative surveys among 

Danish military recruits in 1972, 1982 and 1993. 

Comm Dent Health 1999; 16:80-4. 

10. Willerhausen B, Ernst C-P, Seifert Y, Nauth C. Zur 

Mundgesundheit von Rekruten der Bundeswehr. 

Acta Med Dent Helvet 1997; 2:178-84. 

11. Klimek J, Ganß C, Alffen T. Kariesbefall, Restaurationsarten 

und Fissurenversiegelungen bei 

deutschen Rekruten in den Jahren 1992 und 1996. 

Deutsch Zahnärzt Z 1999; 54:317-20. 

12. Polastri F, Cerato E, Gallesio C, Pancotti G. Stato 

di salute orale in un campione di reclute delle 

varie regioni d’Italia. Minerva Stomatol 1991; 

40:397-403. 

13. Asmyhr O, Grytten L, Grytten J. Changing trends 

in caries experience among male military recruits 

in Norway. Community Dent Oral Epidemiol 

1994; 22:206-7. 

14. Menghini GD, Marthaler TM, Steiner M, Bandi 

A, Schürch E Jr. Kariesprävalenz und gingivale 

Z, Dulčić N. Oralno zdravlje novaka Hrvatske 

vojske. Proceeding of the Third International 

Congress of Croatian Dentists, Zagreb/Croatia, 

October 6-8, 2003. Acta Stomatol Croat 2003; 

37: 307-8. [Abstract]. 


Entzündung bei Rekruten im Jahre 1985: Einfluss 

der Vorbeugung. Schweiz Monatssch Zahnmed 

1991; 101:1119-26. 

15. Menghini GD, Steiner M, Marthaler TM, Weber 

M.W. Rückgang der Kariesprävalenz bei Schweizer 

Rekruten von 1970 bis 1996. Schweiz 

Monatssch Zahnmed 2001; 111:410-6. 

16. Richardson PS, McIntyre IG. Dental treatment 

needs of a cohort of Royal Air Force recruits over 

5 year. Community Dent Health 1996; 13:11-6. 

17. Ceylan S, Acikel CH, Okcu KM, Kilic S, Tekbas 

OF, Ortakoglu K. Evaluation of the dental health 

of the young adult male population in Turkey. Mil 

Med 2004; 169:885-9. 

18. Škec V, Macan JS, Susac M, Jokić D, Brajdić D, 

Macan D. Influence of oral hygiene on oral health 

of recruits and professionals in the Croatian Army. 

Mil Med 2006; 171: 1006-9. 

19. Badel T, Restek-Despotušić S, Kern J, Keros J, 

Šegović S. Karijes novaka Hrvatske vojske u 

2000. godini. Acta Med Croat 2006; 60:315-8. 

20. Marthaler TM. A standard system of recording 

dental conditions. Helv Odontol Acta 1966; 10:1- 

18. 

21. Vulović M, Rajić Z, Popić B, Aurer-Koželj J, 

Nečeva L, Redžepagić S et al. Stanje oralnog 

zdravlja u SFRJ. Zobozdravstveni Vestnik 1988; 

1:3-10. 

22. Artuković D. Prevalence of periodontal diseases 

of adult population of Zagreb, according to the 

criteria by WHO. University of Zagreb, Zagreb 

2001; Master‘s thesis 

23. Lobnik-Gomilšek B. Epidemiological examination 

and caries prevalence in conscripts in 1989, 

1990, and 1991. University of Zagreb, Zagreb 

1993; Master‘s thesis 

24. Künzel W. Rise and fall of caries prevalence in 

Eastern Europe – reasons and consequences. Acta 

Stomatol Croat 1998; 32:587-94. 

25. Szöke J, Petersen PE. Evidence for dental caries 

decline among children in an East European 

country (Hungary). Community Dent Oral Epidemiol 

2000; 28:155-60. 

26. Vrbič V. Reasons for the caries decline in Slovenia. 

Community Dent Oral Epidemiol 2000; 

28:126-32.


Security Perception of a Portable PC User (The Difference Between 

Medical Doctors and Engineers): A Pilot Study 

Krešimir Šolić, Vesna Ilakovac 

Department of Biophysics, Medical Statistics and Medical Informatics, J.J. Strossmayer University of Osijek, School of Medicine, 

Osijek, Croatia 

Corresponding author 

Krešimir Šolić 

J. J. Strossmayer University of Osijek, 

School of Medicine 

Josipa Huttlera 4, 31000 Osijek, Croatia; 

Phone: +385 31 512 809; 

Fax: +385 31 521 866; 

E-mail: kresimir@mefos.hr 


15 June 2008; 


18 September 2008; 

Accepted: 

02 February 2009. 

Med Glas 2009; 6(2): 261-264 

ABSTRACT 

Aim The aim of this pilot study was to compare knowledge on security 

threats and habits in dealing with computer security issues. 

Methods Two groups of researchers and teaching staff, portable 

personal computer (PC) users, coming from different environments 

were included in the study: School of Medicine (n=19) and 

School of Electrical Engineering (n=20). Participants were asked 

to complete an anonymous questionnaire consisting of 21 questions 

about basic demographic data, years of using PC, years of 

owning/using portable PC, position at the School, habits in dealing 

with security issues and knowledge about potential security 

threats. 

Results Both groups demonstrated similar pattern of behaviour 

in dealing with security issues. Participants from the School of 

Electrical Engineering showed a higher level of knowledge in 

three questions about security experts’ terminology (Fisher’s exact 

P

262 


INTRODUCTION 

Security vulnerabilities concerning personal 

data in medical information and communication 

technology (ICT) systems can negatively impact 

patient healthcare, but may also represent a potential 

law violation (1). Data stored in the institutional 

ICT systems are more or less protected by 

different mechanisms and supervised by system 

administrators. Main computers with databases 

are usually stored in secured, air-conditioned 

and dedicated locations. Data safety and security 

mostly depend on institutional policy by means of 

time and resources invested in data protection. 

This is not the case with data stored in 

portable personal computers (PC). While wide 

adoption of mobile computing technology can 

improve information access and enhance workflow 

(2), the data stored in portable computing 

devices are more accessible to potential attackers 

and thieves, physically but also using malicious 

software (3). In addition, such data are at higher 

risk of physical damage due to frequent transportation. 

The user and his/her portable device constitute 

a closed system, which is often connected 

to other systems using different network environments 

with various security levels. The vulnerability 

of such systems depends immensely on 

user awareness about potential threats. Security 

risk behaviour of portable PC users might be a 

threat for their working environment. 

The aim of this pilot study was to compare 

knowledge about security threats, analyse the frequency 

of making backups and investigate user 

habits in dealing with security issues in two research 

groups and teaching staff, namely the portable 

PC users coming from the following different 

environments: School of Medicine and School of 

Electrical Engineering. Users working in the field 

of medicine are compared with users that have a 

much better technical knowledge background. 

PARTICIPANTS AND METHODS 

There was a total of 39 researchers and teaching 

staff of the J.J. Strossmayer University in 

Osijek - School of Medicine (n=19) and School 

of Electrical Engineering (n=20) who own or use 

official (school owned) portable PC on a regular 

basis and who participated in this pilot study. Participants 

were asked to complete an anonymous 

questionnaire comprising 21 questions about basic 

demographic data, years of using a PC, years 

of owning/using portable PCs, position at the 

School, habits in dealing with security issues and 

knowledge about potential security threats. The 

main demographic characteristics, years of using 

a PC, years of owning/using a portable PC and a 

distribution by the position at the School did not 

differ between groups (Table 1). 

Data were presented as absolute frequencies, 

means with standard deviations and medians 

with interquartile range where appropriate. Differences 

in numerical attributes were tested with 

Student’s t-test and Mann-Whitney U test. Differences 

in categorical attributes were tested with 

Fisher’s exact test. All P values were two tailed. 

Analyses were conducted using the SAS software 

(version 8.02, Cary, NC, USA), with significance 

level set at P

Table2. Internet related security issues 

Security issue 

School of 

Medicine 

(n=19) 

School of 

Electrical 

Engineering 

(n=20) 

Accessing Internet services via public computers with questionable 

protection 

on an exceptional 

basis 

8 10 

very rarely 5 6 0.877 

often 5 4 

don’t care about that 1 0 

Internet banking 

user 

User of international 

13 15 0.731 

Web-based e-mail 

services 

13 13 >0.950 

Shopping on the 

Internet 

* Fisher’s exact test 

11 10 0.751 

national Web-based e-mail services (like Gmail, 

Yahoo or other). However, public computers with 

questionable protection were used for accessing 

Internet services on an exceptional basis or very 

rarely in both groups of participants (Table 2). 

Eleven out of 19 participants from the School 

of Medicine and 17 out of 20 from the School of 

Electrical Engineering set a password on their 

portable PCs (Fisher exact test, p=0.082). Four 

participants from each institution respectively 

made security backups more than once a week. 

The distribution of frequency of making security 

backups did not differ between the institutions 

Table 3. Security issues related to backing up data and 

protection against malicious software 

Security issue 

School of 

Medicine 

(n=19) 

School of Electrical 

Engineering 

(n=20) 

Frequency of making security backups of important documents, 

No 

never 1 1 

very rarely 2 1 

from time to time 

once in a month 

12 

0 

7 

5 

0.083 

once in a week 0 2 

more frequently 4 4 

Type of security software installed, No 

antivirus 16 18 0.661 

anti-spyware 8 13 0.205 

spam filter 7 5 0.501 

firewall 11 13 0.748 

Number of various types of security software installed, No 

none 1 2 

1 7 2 

2 3 5 

0.263 

3 3 7 

4 


5 4 

p* 

p* 

Šolić et al Security Perception of a Portable PC User 

(Fisher’s exact test, p=0.083). The same could 

be said for the distribution of number of various 

types of security software installed (Fisher’s exact 

test, p=0.263). The majority of participants 

from both institutions were using antivirus software 

(Table 3). 

Most participants in both surveyed groups 

(14 at School of Medicine group and 18 at School 

of Electrical Engineering group) were familiar 

with the fact that e-mail messages were easily 

intercepted in Internet communication (Fisher’s 

exact test, p=0.235). 

Participants from the School of Electrical 

Engineering showed a higher level of knowledge 

in three questions dealing with terms “hoax”, 

“phishing” and “encryption” (Table 4) 

DISCUSSION 

The results of this pilot study indicate that 

working environment and background do not 

have a great impact on behaviour of highly educated 

portable PC users in connection with security 

issues. 

Internet security presents a challenge in many 

fields of human activity, from commerce, education 

to e-Health (4,5). Accessing Internet services 

such as Internet banking or Web based e-mail client 

via public computers with questionable protection 

is a serious threat to users’ important and 

Table 4. Answers to knowledge questions 

School of 

Question 

Medicine 

(n=19) 

Do you know what is HOAX? 

School of Electrical 

Engineering 

(n=20) 

never heard of it 12 8 

heard, but don’t 

know 

4 0 

heard, but not sure 1 3 

yes, I know 2 9 

Do you know what is PHISHING? 



know 

4 3 


yes, I know 4 13 

Do you know what the data encryption is? 



know 

3 0 


yes, I know 


13 18 

p* 

0.011 

0.008 

0.006 

263

264 


private data. The fact that majority of participants 

from both groups do it on an exceptional basis or 

very rarely implies their awareness of this major 

security issue. 

Furthermore, the Internet is a well known 

source of malicious software. Medical information 

systems are becoming more and more vulnerable 

to attacks by malicious software (6). 

Unaware and unprotected portable PC users who 

have access to a medical information system also 

pose a security threat. The only participant from 

the School of Medicine who has no security software 

on his portable PC is “secured” by using the 

LINUX operating system, whereas the majority 

of the persons tested have at least 2 types of security 

software installed on their portable PCs. Even 

though the reason for such consciousness might 

be just self-protection, it results in a reduced risk 

not only for the user and his portable PC, but also 

for the environment in which they operate. 

The frequency distribution of making security 

backups in both groups is very low. Only 4 

participants from the School of Medicine and 6 

from the School of Electrical Engineering make 

security backups of their important documents 

once a week or more frequently. The difference 

in answers on questions about security experts’ 

REFERENCES 

1. 

2. 

3. 

4. 

5. 

Dantu R, Oosterwijk H, Kolan P, Husna H. Securing 

medical networks. Network Security 2007; 

2007: 13-16. 

Yen-Chiao L, Yan X, Andrew S, Julie A.J. A review 

and a framework of handheld computer 

adoption in healthcare. Int J Med Inform 2005; 

74: 409-22. 

Potter B. Mobile security risks: ever evolving. 

Network Security 200; 2007: 19-20. 

Hawkins S, Yen D.C, Chou D.C. Awareness and 

challenges of Internet security. Information Management 

& Computer Security 2000; 8: 131-43. 

Kluge E-H.W. Secure e-Health: Managing risks 

to patient health data. Int J Med Inform 2007; 76: 

402-6. 

terminology between groups investigated was the 

only difference found between them. 

It seems that information about the importance 

of backups and instructions on how to do 

backup should be presented to each PC user. It 

is considered to be even more important for users 

having a mobile device because their portable 

PCs are not (all the time) part of the secured 

corporate ICT system. Those instructions should 

come in the same box with portable PCs (7). 

The study shows that users’ awareness on security 

risks plays an important role in securing the 

data (8,9). Participants did present great knowledge 

in this matter and their systems are secured. 

The number of portable PC users is growing 

every day, as well as their impact on the security 

of surrounding ICT systems. Although based on a 

rather small sample, the results of the pilot study 

may serve as a starting point for further research 

in security matters in systems consisting of portable 

PCs and their users, as well as in their security 

behavior in different environments. 


6. 

7. 

8. 

9. 


Gobuty D. Defending medical information systems 

against malicious software. International 

Congress Series 2004; 1268: 96-107. 

Phippen A, Furnell S. Taking Responsibility for 

online protection - why citizens have their part 

to play, Computer Fraud & Security 2007; 2007: 

8-13. 

TechNet Security Centre, Microsoft. http://www. 

microsoft.com/technet/security/ (10th of August 

2007) 

Sophos Security Information web page. http:// 

www.sophos.com/security/ (10th of August 2007)

CASE REPORT 

Akutna bruceloza udružena sa 

Coombs-pozitivnom autoimunosnom 

hemolitičkom anemijom i 

diseminiranom intravaskularnom 

koagulacijom 

Nerma Mušić, Eldira Hadžić 

Služba za zarazne bolesti, Kantonalna bolnica Zenica, Bosna i 

Hercegovina 


Nerma Mušić, 

Služba za zarazne bolesti, Kantonalna bolnica Zenica, 

Crkvice 67, 72 000 Zenica, Bosna i Hercegovina 

Phone: +387 32 405 133; Fax: +387 32 405 

E-mail: nermamusic@hotmail.com 

Originalna prijava: 06. decembar 2008.; Korigirana verzija: 

12. januar 2009.; Prihvaćeno: 06. mart 2009. 

Med Glas 2009; 6(2): 265-268 

SAŽETAK 

Hematološke manifestacije bruceloze su različite. 

Akutna hemoliza i diseminirana intravaskularna 

koagulopatija (DIK) jako se rijetko viđaju kod 

bruceloze. Terapijski pristup ovakvim formama 

bolesti je jako kompleksan. U ovom radu prikazan 

je slučaj bolesnika s akutnom brucelozom 

udruženom s Coombs-pozitivnom autoimunom 

hemolitičkom anemijom i diseminiranom intravaskularnom 

koagulacijom. Pacijent je dobro 

reagirao na terapiju antibioticima i kortikosteroidima. 

Ključne riječi: bruceloza, autoimuna hemolitička 

anemija, diseminirana intravaskularna koagulopatija 

UVOD 

Bruceloza je širom svijeta raširena zoonoza 

uzrokovana mikroorganizmom iz roda Brucella 

(1). Bolest zahvata mnoge organe i organske 

sisteme, gastrointestinalni, kardiovaskularni, hematopoetski, 

nervni, koštani, respiratorni, kožni 

i očni (2). Hematološke manifestacije bruceloze 

su različite i obično se manifestiraju kao blaga 

anemija i leukopenija (1-3). Anemija u pacijenata 

sa brucelozom rezultat je poremećaja metabolizma 

željeza tokom infekcije, hipersplenizma, 

krvarenja, supresije koštane srži ili autoimune 

hemolize (2). Teška trombocitopenija, pancitopenija, 

bicitopenija, akutna hemoliza i diseminirana 

intravaskularna koagulacija (DIK) 

su rijetke (2, 3). Infekcija uzrokovana vrstama 

Brucella može rezultirati pojavom sistemskog 

autoimunosnog odgovora kod ljudi (3). Pojava 

Coombs-pozitivne autoimunosne hemolitičke 

anemije kod akutne bruceloze je rijetka (3). Mehanizam 

nastanka trombocitopenije nije potpuno 

jasan, ali neki predloženi mehanizmi su hipersplenizam, 

diseminirana intravaskularna koagulacija, 

supresija koštane srži tokom septikemije, 

hemofagocitoza i imuna destrukcija trombocita 

(4). Autoimunosna hemolitička anemija (AIHA), 

kao jedna od posljedica imunosnog razaranja eritrocita, 

odlikuje se skraćenim vijekom eritrocita 

preko mehanizama domaćinovih antitijela koja 

reagiraju sa vlastitim antigenima (5). Može biti 

dio kliničke slike infekcija uzrokovanih različitim 

uzročnicima. Najčešće su to vrste Plasmodium, 

Haemophilus influenzae, Escherichia coli, Salmonella 

spp., Shigella spp., Mycoplasma pneumoniae, 

citomegalovirus, varicella zoster i herpes 

simplex virus, virus influenzae A (5). Klinički autoimuna 

hemolitička anemija može se očitovati 

različito, kao teška hemolitička anemija sve do 

akutnih hemolitičkih kriza sa hemoglobinurijom 

i akutnom bubrežnom insuficijencijom (5). 

Diseminirana intravaskularna koagulacija (DIK) 

često nastaje u sistemskoj upali uzrokovanoj endotoksinom 

koji istovremeno aktivira imunosni 

(monocitno-makrofagni) sistem i endotelne stanice 

koji luče tkivni faktor (6). Između ostalih, i 

intravaskularna hemoliza jeste stanje kod kojeg 

se javlja DIK (6). 

U ovom radu prikazan je slučaj bolesnika 

s teškim oblikom akutne bruceloze udružene 

sa kliničkim i hematološkim nalazom Coombspozitivne 

autoimunosne hemolitičke anemije i 

diseminirane intravaskularne koagulacije. 

265

266 


PRIKAZ SLUČAJA 

Šezdesetdvogodišnji muškarac hospitaliziran 

je u Službi za zarazne bolesti Kantonalne 

bolnice Zenica krajem treće sedmice od pojave 

simptoma gubitka apetita, opće slabosti i 

malaksalosti. Dan prije dolaska u bolnicu imao 

je povišenu temperaturu i otežano kretanje. Na 

dan prijema bolesnik je bio dezorijentiran, te je 

teško uspostavljen kontakt. Bolesnik je stanovao 

u seoskom domaćinstvu, bavio se uzgojem ovaca 

i preradom mesa. 

U objektivnom statusu dominirala je febrilnost, 

dezorijentacija i dehidratacija. Na odjelu 

je šest dana bila prisutna visoka febrilnost, a 

četvrtog dana po prijemu razvili su se znakovi 

afekcije jetre, hemolitičke anemije i diseminirane 

intravaskularne koagulacije. Bolesnik je povremeno 

bio konfuzan (Tabela 1). 

Dijagnoza bruceloze postavljena je na osnovu 

pozitivnih seroloških testova, Rose Bengal 

testa, RVK na brucelozu čiji je titar iznosio 1:128, 

te ELISA-testa na brucelozu koji je bio pozitivan 

na sve tri frakcije (IgM, IgG i IgA). Serološki 

testovi na viruse hepatitisa A, B i C bili su negativni. 

Dijagnostička procedura nadopunjena je 

ultrazvučnim nalazom hepatosplenomegalije, kompjuteriziranom 

tomografijom (CT) mozga i citobiohemijskim 

nalazom likvora koji su bili uredni. 

Direktni Coombsov test bio je pozitivan 

četvrtog dana hospitalizacije, kada je došlo i do 

pojave ikterusa. Laboratorijski nalazi ukazivali 

su na značajnu leziju jetre, hemolizu i znakove 

DIK-a. U perifernom razmazu krvi ustanovljeno 

je parcijalno megaloblastno sazrijevanje, trombocitopenija 

i toksične granulacije (Tabela 2). 

Petog dana nakon što je započeto liječenje 

kombinacijom gentamicina i doksiciklina uz kortikosteroide, 

bolesnik je postao afebrilan i postepeno 

je došlo do oporavka. 

Tabela 1. Objektivni patološki nalaz kod bolesnika oboljelog 

od bruceloze kod prijema u bolnicu 

Organski sistem Nalaz 

Glava i vrat 

ikterus očnih sklera 

znaci dehidratacije sluznica 

Trbuh 

meteorizam 

hepatosplenomegalija 

Koža ikterus, petehije 

Šest mjeseci nakon otpusta iz bolnice, bolesnik 

je imao uredne kontrolne nalaze (krvna slika, 

transaminaze, bilirubin, laktatdehidrogenaza, 

gama glutamil-transferaza, alkalna fosfataza, proteinogram, 

željezo u krvi, protrombinsko vrijeme), 

ultrazvuk abdomena i negativan Coombsov test. 

Brucele su fakultativno intracelularne bakterije 

(7). Neki faktori virulencije brucela esencijalni 

su u invaziji domaćinovih ćelija, dok su 

drugi odlučujući u izbjegavanju eliminacije od 

strane domaćina (8). Ove bakterije posjeduju 

nekonvencionalni non -endotoksični lipopolisaharid 

koji im omogućava otpornost na antimikrobijalni 

napad i modulira domaćinov imunosni 

odgovor (7, 8). Ključni aspekt virulencije brucela 

jeste njena sposobnost proliferacije unutar 

profesionalnih i neprofesionalnih fagocita (9). U 

uslovima gdje je tijelo izloženo lipopolisaharidu, 

pretjerano ili sistematski, kao kad lipopolisaharid 

uđe u krvnu struju, može doći do sistemske 

upalne reakcije dovodeći do multiplog organskog 

oštećenja, šoka, a potencijalno i smrti (9). 

Tabela 2. Rezultati značajnih laboratorijskih nalaza pri 

prijemu i otpustu bolesnika oboljelog od bruceloze 

Vrsta analize 

Rezultati analiza 

kod pri- kod 

jema otpusta 

Referentne 

vrijednosti 

Sedimentacija 

(mm /sat) 

35 10 10 

Eritrociti (x 106/L) 3,14 4,42 4,30 – 5,70 

Hemoglobin (g/L) 9.2 14,1 14,0 – 18,8 

Leukociti (x 103/L) 3.7 6.6 4.0 – 10,0 

Trombociti (x 103/L) 29 253 150 -400 

Protrombinsko 

vrijeme (%) 

Aktivirano parcijalno 

17 13,4 11.5 – 15 

tromboplastinsko 

vrijeme (sec.) 

6.1 49,9 29 - 37 

Fibrinogen (g/L) 1,00 3,29 1.8 - 3.5 

D-dimeri (ng/L) 3000 598

Akutna hemoliza i DIK jako se rijetko viđaju 

kod oboljelih od bruceloze, u 0,5%, odnosno 

0,1% slučajeva (2). Poremećaji koagulolitičkog 

sistema kod bruceloze također su veoma rijetki 

i javljaju se u oko 1% slučajeva. U tom slučaju 

nastale promjene posljedica su oštećenja zidova 

kapilara brucelama, kao i stvorenim imunim 

kompleksima u toku infekcije (10). U Službi za 

zarazne bolesti Kantonalne bolnice u Zenici, u 

periodu od 01. 01. 2002. do 01. 11. 2008. godine 

od bruceloze je liječen 631 bolesnik, a samo 

jedan bolesnik (0,16%) je imao kliničke i laboratorijske 

parametre i AIHA i DIK-a (neobjavljeni 

podaci, N. Mušić, Služba za zarazne bolesti, 

Kantonalna bolnica Zenica, 2008.). 

Dijagnoza bruceloze prikazanog bolesnika 

postavljena je na osnovu pozitivnih seroloških 

testova, a dijagnoza AIHA i DIK-a na osnovu 

laboratorijskih analiza i pozitivnog Coombsovog 

testa. U kliničkoj slici bolesnika dominirali su 

simptomi lezije jetre udružene sa febrilnošću i 

hemolitičkom anemijom. Serološkim testovima 

isključena je mogućnost hepatalnog oštećenja 

hepatotropnim virusima. Bolesnik je liječen kombinacijom 

antibiotika. Afebrilnost koja je nastala 

petog dana liječenja, uz postepeno poboljšanje 

općeg stanja i laboratorijskih nalaza, te porasta 

trombocita nakon terapije kortikosteroidima, uz 

laboratorijski verificiran prestanak hemolize i 

negativizaciju Coombsovog testa, sugerirali su 

imunološku osnovu ovih zbivanja. 

Kod bolesnika sa temperaturom, znacima 

oštećenja jetre i hematološkim poremećajima, pa 

čak i onim rijetkim kao što je AIHA i DIK, u diferencijalnoj 

dijagnozi treba uvijek imati na umu 

brucelozu, posebno u endemskim geografskim 

područjima kao što je Zeničko-dobojski kanton. 



ne postoji. 

LITERATURA 

1. 

Alici O, Kasapoglu B, Alkan R, Sarifakioglu E, 

Akgedik R, Bozalan R, Kosar A,. Sahin H. Case 

report: An unusual presentation of acute brucellosis 

with thrombocytopenia and maculopapu- 

Case report 

2. 

lar rash. J Infect Developing Countries 2007; 

1:220-3. 

Dilek I, Durmus A, Krahocagil M K, Akdeniz H, 

Karsen H, Baran AI, Evirgen O. Hematological 

complications in 787 cases of acute brucellosis in 

Eastern Turkey. Turk J Med Sci 2008; 38: 421-4. 

3. Sari I, Kocygit I, Altuntas F, Kaynar L, Eser B. 

An unusual case of acute brucellosis presenting 

with Coombs-positive autoimmune hemolytic 

anemia. Intern med 2008; 47: 1043-5. 

4. Yalaz M, Mehmet T, Arslan, Kurugol Z. Thrombocytopenic 

purpura as only manifestation of 

brucellosis in a child. Turk J Pediatr 2004; 46: 

265-7. 

5. Nemet D. Anemije nepoznatog i višetrukog mehanizma 

nastanka U: Božidar Vrhovec i suradnici. 

Interna medicina. Treće promjenjeno i dopunsko 

izdanje. Zagreb: Naklada Ljevak, 2003: 1017-23. 

6. Stančić V. Sindrom diseminirane intravaskularne 

koagulacije (DIK) ili sindrom potrošne 

koagulopatije. http:/www.hdubl.hr/Predavanja/ 

Stančić%20Vladimir.doc. 

14.01.2009.). 

(Datum pristupa 

7. Lapaque N, Moriyon I, Moreno E, Gorvel JP. 

Brucella lipopoliysaccharide acts as a virulence 

factor. Curr Opin Microbiol 2005; 8:60-6. 

8. Fugier E, Pappas G, Gorvel JP. Virulence factors in 

brucellosis:implications for aetiopathogenesis and 

treatment. Expert Rev Mol Med 2007; 9:1-10. 

9. Cardoso PG, Macedo GC, Azevedo V, Oliveira 

SC. Brucella spp. noncanonical LPS: structure, 

biosynthesis and interaction with host immune 

system. Microb Cell Fact 2006; 5:13. 

10. Čengić Dž. Poremećaji hemostaze i fibrinolize 

u infektivnim bolestima. Sarajevo: Nacionalna i 

Univerzitetska biblioteka Bosne i Hercegovine, 

1997: 61, 85. 

Acute brucellosis associated with 

Coombs-positive autoimmune 

hemolytic anemia and disseminated 

intravascular coagulation (DIC) 

Nerma Mušić 

Department for Infectious Diseases, Cantonal Hospital Zenica, 


ABSTRACT 

Hematological manifestations of brucellosis are 

different. Acute hemolysis and disseminated intravascular 

coagulopathy are rarely seen in the 

course of brucellosis. Therapeutic approach to 

267

268 


these forms of diseases is extremely complex. 

This paper presents a case of acute brucellosis 

manifested by coombs-positive autoimmune 

hemolytic anemia and disseminated intravascular 

coagulation. The patient responded well to antibiotic 

and corticosteroid therapy. 

Key words: brucellosis, autoimmune hemolytic 

anemia, disseminated intravascular coagulopathy 

Original submission: 06 December 2008; Revised submission: 

12 January 2009; Accepted: 06 March 2009. 

CASE REPORT 

Pneumolabirint 

\enad Hodžić, 

Služba za bolesti uha, grla, nosa i maksilofacijalnu hirurgiju, 

Kantonalna bolnica Zenica, Zenica, Bosna i Hercegovina 


\enad Hodžić, 

Služba za bolesti uha, grla, nosa i maksilofacijalnu hirurgiju, 

Kantonalna bolnica Zenica, Crkvice 67, 72000 Zenica 

Tel.: +387 32 405 133; Fax.: +387 32 405 534 

E-mail: eminh@bih.net.ba 

Originalna prijava: 25. februar 2009.; Korigirana verzija: 01. 

april 2009.; Prihvaćeno: 19. april 2009. 

Med Glas 2009; 6(2): 268-271 

SAŽETAK 

Nalaz zraka u labirintu uha, nakon frakture temporalne 

kosti glave, pomoću kompjuterizovane 

tomografije (CT), rijetka je klinička manifestacija. 

Prateći simptomi su vertigo, oštećenje 

sluha i često perilimfatična fistula. U radu je 

opisan slučaj petnaestogodišnjeg mladića kojem 

su kliničke tegobe nastale nakon pada sa visine. 

Pneumolabirint je ostao neprepoznat gotovo dvije 

sedmice, a otkriven je na CT snimcima temporalne 

kosti. Pacijent je liječen konzervativno. 

Budući da je liječenje započeto kasno, krajnji rezultat 

ove ozljede bio je potpuni i trajni gubitak 

funkcije ozlijeđenog uha. 

Ključne riječi: pneumolabirint, fraktura temporalne 

kosti, gubitak sluha, perilimfatična fistula 

UVOD 

Termin pneumolabirint prvi put se spominje 

1984. godine, kada su Mafee i sur., na snimcima 

dobijenim kompjuterizovanom tomografijom 

(CT) temporalne kosti, opisali pacijenta kod 

kojeg je nastala nagla nagluhost i vertiginozne 

smetnje, prisustvo zraka u labirintu i fraktura 

pločice stapesa (1). Naime, malo je objavljenih 

radova koji prikazuju slične slučajeve. Opisani 

su slučajevi pneumolabirinta kod pacijenata 

sa barotraumom, frakturom temporalne kosti, 

perilimfatičnom fistulom, komplikacijama stapedektomije 

(2-6). U ovom radu opisat ćemo 

slučaj pacijenta sa frakturom lijeve temporalne 

kosti, udružene sa nastankom pneumolabirinta, 

nagle gluhoće i šuma lijevog uha, te vertiginoznih 

smetnji. 


Petnaestogodišnji mladić, prilikom pada sa 

visine od oko dva metra, u etiliziranom stanju, 

zadobio je udarac u glavu, rame i potkoljenicu, 

na lijevoj strani tijela. Neposredno nakon pada, 

uz simptome vrtoglavice, mučnine, povraćanja 

(nekoliko puta), pacijent je bio nestabilan u hodu 

i nije se sjećao pada. Sljedeća dva dana ležao 

je kod kuće, uz izraženu vrtoglavicu prilikom 

pokretanja glave, dezorijentiranost, somnolenciju 

i nestabilnost u hodu. Šum u lijevom uhu i naglo 

slabljenje sluha u lijevom uhu, pojavili su se 

sljedećeg dana poslijepodne. U sljedeća 2-3 sata 

pojavilo se pojačanje šuma, koji je od tada postao 

stalan, te jako izražen oslabljen sluh na lijevom 

uhu. Sljedeća 3-4 dana pacijent je imao osjećaj da 

ponešto i čuje na lijevo uho, ali nakon toga, i taj 

osjećaj je nestao. Istovremeno je subjektivno došlo 

do smanjenja vrtoglavice, mučnine i nestabilnosti 

u hodu. Otoskopijom, kod kliničkog pregleda, ustanovljen 

je obostrano intaktan bubnjić normalnog 

izgleda. Nije bilo znakova izljeva u srednje uho, 

test na prisustvo fistule bio je negativan, a Romberg 

test pozitivan sa zanošenjem udesno i natrag. 

Nije bilo znakova pareze nervusa facialisa. 

Osnovni laboratorijski nalazi urađeni su u nekoliko 

navrata i bili su u fiziološkim granicama. 

Tonalni audiogram pokazao je desno uredan 

prag sluha, a lijevo gluhoću. 

Timpanometrija je pokazala desno tip A timpanometra, 

a lijevo tip B timpanometra. 

CT piramida temporalne kosti pokazao je 

transverzalnu frakturu piramide i mastoida lijeve

temporalne kosti, uz prisutnost tečnog sadržaja 

u većini mastoidnih ćelija. Fraktura je bila usmjerena 

kroz labirint vestibuluma, kohleu, dno 

meatus acusticus internus, a u labirintu je ustanovljeno 

prisustvo zraka, te dijagnosticiran 

pneumolabirint. Na osikulama i unutar kavuma 

nije bilo vidljivih promjena (Slika 1). 

Pacijent je liječen ambulantno, uz simptomatsku 

terapiju i kućnu njegu. Nakon mjesec dana, 

subjektivno vertiginozne smetnje kod pacijenta su 

nestale, ali je ostao stalno prisutan šum u lijevom 

uhu, te potpuni gubitak sluha na lijevom uhu. 

Dijagnoza frakture lijeve temporalne kosti sa 

pneumolabirintom, postavljena je nakon 12 dana 

od dana ozljeđivanja, na osnovu CT nalaza piramida 

temporalnih kostiju. Dijagnoza je bila otežana 

uslijed nepostojanja vidljive lezije na koži glave, 

etiliziranosti pacijenta i urednog otoskopskog nalaza. 

Intenzivne tegobe od strane labirinta, nastale su 

poslije više od 24 sata, u vidu naglo nastalog šuma 

u lijevom uhu i intenzivne nagluhosti na istom 

uhu, kada je nastao gubitak sluha na lijevom uhu 

i ostao samo subjektivni osjećaj percepcije zvuka. 

Trajanje ovog pogoršanja stanja sluha od svega nekoliko 

sati i njegov nagli nastanak upućivali su na 

mogućnost da pneumolabirint nije nastao odmah 

nakon povrede, nego da je možebitno isprovociran 

nekim postupcima bolesnika (povraćanje, 

saginjanje, naprezanje). Implozivne i eksplozivne 

sile su potencijalni uzrok nastanka perilimfatične 

fistule i pneumolabirinta (10). Implozivne sile 

mijenjaju tlak u srednjem uhu koji pritišće ovalni 

i okrugli prozor (fossulu ante fenestram), te Hyrtleovu 

fissuru. Porast tlaka može uzrokovati kompresivna 

trauma uha, Valsalvina proba, kihanje sa 

zatvorenim nosom (10). 

Slika 1. Kompjuterizovana tomografija lijeve temporalne kosti. 

Strelica pokazuje prisustvo zraka u labirintu unutrašnjeg 

uha. Lanac slušnih koščica je intaktan i u bubnjištu nema 

tečnog sadržaja. Desno od strelice je frakturna pukotina. 

(Služba za bolesti uha, grla, nosa i maksilofacijalnu hirurgiju, 

Kantonalna bolnica Zenica, 2008.) 

Case report 

Eksplozivne sile u vidu kašljanja, kihanja ili 

defekacije, koje se prenose u unutrašnje uho kroz 

kohlearni akvedukt i laminu kribrozu, povećavaju 

pritisak cerebrospinalnog likvora (CSL) (10). 

Potencijalna ulazna vrata za ulazak zraka u labirint 

mogu biti ovalni i okrugli prozor, mikrofisure 

između stražnjeg polukružnog kanala i okruglog 

otvora (fossula ante fenestram) (9). Prisustvo zraka 

u skali timpani ili skali mediji znak je traume 

kohleje (16). Mjehurić zraka onemogućava širenje 

putujućem valu duž bazilarne membrane, što se 

očitovalo na timpanogramu i kod našeg pacijenta 

(timpanogram tip B) (16). Curenje perilimfe 

uzrokuje relativno povećanje endolimfatičnog 

tlaka, što, uz nizak tlak perilimfe, uzrokuje 

endolimfatični hidrops, a koji je uzrok vrtoglavice 

i nestabilnosti pacijenta (8, 17). 

Jednom nastala komunikacija između 

unutrašnjeg i srednjeg uha dovodi do gubitka perilimfe, 

relativnog hidropsa endolimfe i pratećih 

simptoma. Prisustvo pneumolabirinta može olakšati 

dijagnozu perilimfatične fistule (11, 15), koja sama 

po sebi ne znači i postojanje pneumolabirinta, dok 

prisustvo pneumolabirinta obavezno ukazuje i na 

postojanje perilimfatične fistule. Nalaz zraka u bazalnom 

zavoju kohleje jeste dobar pokazatelj postojanja 

perilimfatične fistule, te upućuje na potrebu 

eksploracije i kirurškog zbrinjavanja fistule (12, 

17). Rano kirurško zbrinjavanje perilimfatične fistule 

onemogućava teška oštećenja uha, kao što su 

gluhoća, meningitis, labirintitis (12, 17). 

Iako, u našem slučaju, nismo našli pozitivan 

znak postojanja perilimfatične fistule, nalaz tečnosti 

u mastoidnim ćelijama upućivao je na njezino postojanje, 

a lokalizacija frakturne pukotine ukazivala 

je na postojanje komunikacije između mastoidnih 

ćelija i labirinta. Frakturna pukotina nije zahvatala 

dio labirinta koji ujedno predstavlja i medijalni zid 

bubnjišta. Intaktan lanac slušnih koščica i bubna 

opna dodatno su potvrdili odsustvo znaka postojanja 

perilimfatične fistule. 

Poredeći konzervativni i kirurški tretman, 

neki autori, u odsustvu znakova postojanja 

perilimfatične fistule i težih simptoma, 

preporučuju inicijalno konzervativno liječenje 

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270 


(14). Konzervativno liječenje, pored antibiotika, 

kortikosteroida i simptomatske terapije, podrazumijeva 

i postupke kojima se prevenira nastanak 

eksplozivnih i implozivnih sila za koje se pretpostavlja 

da su bitan faktor u nastanku pneumolabirinta 

- mirovanje, antiemetici, sedativi, položaj 

glave u blagoj elevaciji, regulisanje stolice (6). 

Eksperimentalno, kod zamoraca, utvrđeno je 

kako se, nakon resorpcije zraka, funkcija labirinta 

u potpunosti povratila (4, 5). 

U unutrašnjem uhu, zrak se može kretati 

ovisno od položaja glave, a što se može vidjeti 

na CT snimcima visoke rezolucije (13). Stoga je 

za dijagnostiku pneumolabirinta ključna pretraga 

CT-om sa tankim slojevima (od 1 do 1,5 mm debljine), 

radi boljeg kontrasta u prikazivanju odnosa 

zrak-kost, nego nuklearna magnetna rezonanca 

(MRI) (7). Rano otkrivanje pneumolabirinta i 

perilimfatične fistule, rani početak terapije, bilo 

konzervativno ili hirurški, kao i niz drugih postupaka 

i preporuka u njihovom tretmanu, jako su 

važni u liječenju teških oštećenja sluha i prevenciji 

mogućih teških komplikacija. U ovom slučaju od 

velike koristi bila bi rano započeta konzervativna 

terapija (odmah nakon ozljeđivanja) antibioticima, 

kortikosteroidima, uz regulaciju probave, mirovanja, 

blagu elevaciju glave, antitusika, antiemetika, 

te praćenje audioloških parametara kao što 

su tonalna audiometrija, BERA (engl. brain steam 

auditory evoked potentials), timpanometrija. 

ZAHVALE/IZJAVE 


ne postoji. 

LITERATURA 

1. Mafee MF,Vaslvassori GE, Kumar A, Yannisas 

DA, Marcus RE. Pneumolabyrinth. A new radiologic 

sign for fracture of the stapes footplate. Am 

J Otol 1984; 5:374-5. 

2. Scheid SC, Feehery JM, Willcox TO, Lowry LD. 

Pneumolabyrinth: A late complication of stapes 

surgery. Ear Nose Throat J 2001; 80:750-3. 

3. Isaacson JE, Laine F, Williams GH. Pneumolabyrinth 

as computed finding in poststapedectomy 

vertigo. Ann Otol Rhinol Laryngol 1995; 974-6. 

4. Yanagihara N, Nishioka I. Pneumolabyrinth in 

periliymphatic fistula: report of tree cases. AmJ 

Otolaryngol 1987; 8:313-8. 

5. Nakashima T, Kaida M, Yanagita N. Round window 

membrane rupture and inner ear damage due 

to barotrauma. Acta Otolaryngol Suppl. 1992; 

493:57-62. 

6. McGee MA, Dornhoffer JL. A case of barotrauma-induced 

pneumolabyrinth secondary to 

perilyphatic fistula. Ear Nose Throath J 2000; 

76:456-9. 

7. Nishizaki K, Yamamoto T, Akagi H, Ogawa T, 

Masuda Y. Pneumolabyrinth: imaging case of the 

month. Am J Otol 1998; 19:860-1 

8. Lyos AT, Marsh MA, Jenkins HA, Coker NJ. Progressive 

hearing loss after transverse temporal 

bone fracture. Arch Otolaryngol Head Neck Surg 

1995; 121:795-9. 

9. Meyerhoff WL, Marple BF. Perilymphatic fistula. 

Otolarygol Clin North Am 1994; 27:411-26. 

10. Goodhill V. Sudden deafens and round window 

rupture. Laryngoscope 1971; 81:1462-74. 

11. Sheridan MF, Hetherington HH, Hull JJ. Inner 

barothrauma from scuba diving. Ear Nose 

Throath J 1999; 78:181. 

12. Pullen FW, Rosenberg GJ, Cabeza CH. Sudden 

hearing loss in dives and flyers. Laryngoscope 

1979; 9:137-38. 

13. Kobayashi T, Sakurada T, Ohyama K. Inner ear 

injury caused by air intrusion to the scala vestibuli 

of the cochlea. Acta Otolaryngol 1993; 

113:725-30. 

14. Lao WW, Niparko JK. Assesment of changes in 

cochlear function with pneumolabyrinth after middle 

ear trauma. Otol Neurotol 2007; 28:1013-7. 

15. Lo S-H, Huang Y-C, Wang P-C. Pneumolabyrinth 

associated with perilymph fistula. Chang Gung 

Med J 2003; 26:690-94. 

16. Nomura Y. Perlymph fistula: concept, diagnosis 

and management. Acta Otolaryngol (Suppl) 

1994; 514:52-4. 

17. Nomura Y, Okuno T, Hara M, Young YH. 

”Floating” labirynth. Pathophysiology and treatment 

of perilymph fistula. Acta Otolaryngol 

1992;112:186-91. 

Pneumolabyrinth 

\enad Hodžić 

Department for Ear, Nose, Throat and Maxillofacial Surgery, 

Cantonal Hospital Zenica, Bosnia and Herzegovina 

ABSTRACT 

Computed tomography (CT) revealing pneumolabyrinth 

after temporal bone fracture is a rare 

clinical finding. Accompanying symptoms are: 

vertigo, hearing loss and very often perilymphatic 

fistula. This paper presents a case of a

fifteen-year old boy with clinical discomfort after 

falling down from a height. Pneumolabyrinth 

was diagnosed by CT scan of the temporal bone 

and it had remained unrecognized for almost two 

weeks. The patient was treated conservatively. 

As the hospital treatment started too late the final 

result of this injury was complete and permanent 

hearing-loss of the impaired ear. 

Key words: pneumolabyrinth, temporal bone 

fracture, hearing loss, perilymphatic fistula 

Original submission: 25 February 2009; Revised submission: 

01 April 2009; Accepted: 19 April 2009; 

CASE REPORT 

Sphenochoanal polyposis 

Ivana Pajić-Penavić 1 , Davorin \anić 1 , Ljubica 

Fuštar-Preradović 2 

1 Department of Otorhinolaryngology Head and Neck Surgery, 

2 Department of Pathology and Cythology; General Hospital “Dr. 

Josip Benčević” Slavonski Brod, Croatia 


Ivana Pajić-Penavić, 

Department of Otorhinolaryngology Head and Neck Surgery 

General Hospital “Dr. Josip Benčević’’ 

Andrije Štampara 42, 35 000 Slavonski Brod, Croatia 

Phone: +385 35 445 643 

E-mail: ivana.pajic-penavic@sb.t-com.hr 

Original submission: 04 December 2008; Revised submission: 

09 February 2009; Accepted: 04 May 2009. 

Med Glas 2009; 6(2): 271-273 

ABSTRACT 

The reports of sphenochoanal polyps in the literature 

are relatively rare. Computed tomography 

and nasal endoscopy contribute in diagnosis 

of sphenochoanal polyps. Simple polypectomy 

which partialy leaves a polyp inside the sphenoid 

sinus increases the risk of a relapse. Using 

powered instrument-assisted endoscopic sinus 

surgery we surgically removed sphenochoanal 

polyp in a ten year old boy. We wide opened the 

orifice of sphenoid sinus and removed the cystic 

polyp part from sphenoid sinus. At the annual 

follow-up examination, this patient remains free 

of signs of polyp recurrence. 

Key words: spenochoanal polyposis, endoscopic 

surgery, computed tomography (CT scan) 

INTRODUCTION 

Choanal polyps are rare benign mucous tumors 

of the nose and the paranasal sinus which 

grow from the sinus orifice and spread through 

nasal meatus into choanae and nasopharynx . 

They make 3-6 % of all the polyps of the nose 

(1). Based on the origin of the polyp’s petiole, 

polyps are divided into the three types: antrochoanal 

(originating in the maxillary sinus), 

ethmoidochoanal (originating from the etmoid 

sinus) and sphenochoanal (originating from the 

sphenoid sinus) (2). 

Polyps whose source is in the orifice or in 

sphenoid sinus are distinctly rare (2,3). They 

were first described by Zuckerkandl in 1892 (4,5). 

Clinically, the glistening and pale masses are 

identical to typical nasal polyps; careful inspection 

using endoscopy can disclose a stalk leading 

to the sinus of origin (6). It must be emphasized 

that the stalk of antrochoanal polyp can be easily 

visualized but it is very difficult to visualize 

sphenoid orifice in children even without polyps. 

In case of sphenochoanal polyp only stalk from 

sphenoethmoid recess can be seen. In general, 

the diagnosis of choanal polyps is established by 

nasal endoscopic examination and CT (3,6). 

In this paper we presented a case of endoscopic 

treatment of a ten year old male with the 

sphenochoanal polyp. 

CASE REPORT 

Case report 

The patient was a 10-year old male, with 

symptoms of heavy respiration through his nose, 

with incessant frontal rhinorrhea, purulent mucous 

discharge with occasional snoring. He had 

been adenoidectomised three years earlier in another 

hospital due to heavy respiration through the 

nose. After the operation he showed no postoperative 

improvement. Using a front rhinoscopia, an 

abundance of mucous and purulent secretion was 

found in both nasal cavities. Physical examination 

by endoscope revealed an intranasal pearly 

271

272 


polyp creation in the right nasal cavity, situated 

in a lower nasal meatus and in left nasal cavity, 

obstructing the entire nasal cavity (Figure 1). 

Computed tomography (CT scan) of nasal 

cavity and paranasal sinuses in axial and coronary 

projection confirmed a shading of both sphenoid sinuses, 

partly of frontal ethmoids left, and both nasal 

cavities alongside unobstructed maxillary sinuses. 

With the powered instrument-assisted endoscopic 

approach under general endotracheal 

anesthesia, we identified a pearly polyp-creation 

centered between the middle nasal concha and 

a septum of the left nasal cavity with a petiole 

spanning from the left sphenoid sinus. We endoscopically 

removed the polyp petiole intersection 

which originates from the anterior wall of the left 

sphenoid sinus. Enlarging the orifice of the sphenoid 

sinus we removed a cystic part of intrasinusal 

polyp along with mucous membrane (Figure 2). 

Free orifices of the maxillary sinuses are 

mutually displayed. Pathologic analysis of the 

creation confirms a diagnosis of chronic polypus 

inflammation. The patient experienced successful 

operative and post–operative process without 

any complications. One year after this procedure 

was completed, the left sphenoid sinus orifice is 

wide opened and both nasal cavities and the sinus 

remain free of recurrence. 

A polyp which grows from the singular sinus 

and spreads out through choanes into nasopharynx 

is called the choanal polyp. Sphenochoanal 

polyps are the polyps whose roots arrive from 

sphenoid sinuses. Compared with common nasal 

polyposis and antrochoanal polyps, sphenochoanal 

polyps are relatively rare, with only 35 

Figure 1. Endoscopic picture of a sphenochoanal polyp 

centered between a middle nasal concha and septum (I. Pajić 

Penavić, 2007.) 

cases reported in the English literature to date 

(7). Histologically, majority of all the polyps look 

similar and include a cystic center that is usually 

caused by gland hyperplasia which is surrounded 

by edematous parenchyma with infiltration of 

inflammatory cells whereas the polyp surface is 

covered with respiratory epithelium. This histological 

appearance is not always present in case 

of sphenochoanal polyps (8). There are numerous 

theories explaining polyp development. 

Two of them are mostly described by Berg and 

Mills (8,9). Sphenochoanal polyp occurs evenly 

in male and female population from childhood 

till the fourth decade of life (10). The polypoide 

mass in our case contains few mucous glands and 

has a myxoid stroma, with variable densities of 

inflammatory cells concentrated near the surface 

which can confirm the polyp development as a 

result of mucocela expansion caused by blockade 

and burst of acino-mucus glands in bacterial 

rhinitis phase during the period of recovery from 

a chronic infection according to Mills (9). 

Clinically, choanal polyps produce symptoms 

of nasal obstruction, rhinorrhea, pain in the facial 

area, partial deafness caused by dysfunction 

of Eustachian tube, otalgia, snoring and a presence 

of a creation in nasal and oral cavity (11). 

Sphenochoanal polyps as the one from our case 

are clinically present as unilateral, solitary, bluish 

or yellowish mass involving the nasal fossa between 

the middle nasal concha and septum and the 

choana can differ from antrochoanal polyp which 

takes up osteomeatus complex between the middle 

nasal concha and the lateral wall of the nasal cavity. 

Both polyp types can obstruct nasal cavities 

Figure 2. Endoscopic view of wide opened orifice of a sphenoid 

sinus (I. Pajić-Penavić, 2007.)

and may spread through the choanae into the nasopharynx, 

then spread down into the oral cavity. 

Frontal rhinoscopy, flexible and rigid nasal endoscopies 

are obligatory for the diagnosis of sphenochoanal 

polyposis. They are recommended for the 

description of a location of the polyp petiole. 

To distinguish an antrochoanal polyp from 

sphenochoanal polyps computed tomography or 

magnetic resonance of the paranasal sinuses can 

be used (12). 

Sphenochoanal polyp can be seen on CT 

scan as an opacification of the sphenoid sinus 

and mass in common meatus extending to the 

nasopharynx without evidence of pathology in 

maxillary sinuses. When choanes are filled with 

necrotic sphenochoanal polyposis CT with contrast 

or angiographia towards suspect angiofibroma 

is recommended (13). Surgical treatment 

of sphenochoanal polyp involves endoscopic removal 

of choanal portion of the polyp and widening 

ostium of sphenoid sinus with no need of 

middle meatal antrostomy as it is suggested in 

treatment of antrochoanal polyp (6,13). 

A comprehensive discussion of the differential 

diagnosis should include the possibility of an 

antrochoanal polyp, hypertrophic adenoid, Tornwald’s 

cyst, pituitary tumor, lymphoma, meningoencephalocela, 

angiofibroma, inverted papilloma 

and fungal rhinosinusitis (13,14). Treatment of 

sphenochoanal polyposis involves complete surgical 

removal. Choanal polyposis recidivate in 25% 

cases if removed by simple intranasal removal of 

polyp by forceps. Endoscopic approach with a review 

of petiole and wide microdebrider or forceps 

removal of the polyp in nasal cavity and in the 

sinus is a surgical technique of choice (15). 

In conclusion, sphenochoanal polyp is an 

extremly rare type of choanal polyp and it can 

be easily confused with antrochoanal polyp. An 

adequate preoperative preparation with CT scan 

and endoscopy is crucial to establish an exact diagnosis 

and for planning of an adequate surgical 

technique to reduce the percentage of possible 

polyp recidivism. 



Case report 

REFERENCES 

1. Eloy PH, Evrard I, Bertrand B, Delos M. Choanal 

polyp of sphenoid origin. Acta Otolaryngol Belg 

1996; 50:183-9. 

2. Chen JM, Schloss MD, Azouz ME. Antrochoanal 

polyp: a 10 year retrospective study in the pediatric 

population with a review of the literature. J 

Otolaryngol 1989; 18:168-72. 

3. Lessa Marcus M, Voegels Richard L, Padua F, 

Wiikmann C, Romano Fabrozio R, Butugan O. 

Sphenochoanal polyp: diagnose and treatment. 

Rhinology 2002; 40:215-6. 

4. Stammberger H. Functional Endoscopic Sinus 

Surgery. Pennsylvania, Philadelphia: BC Decker, 

1991. 

5. Prasad U, Sagar PC, Shahul Hameed O.A.N. 

Choanal polyp. J Laryngol Otol1970; 84: 951-4. 

6. Tosun F, Yetiser S, Akcman T, Özkaptan Y. Sphenochoanal 

polyp: endoscopic surgery. Int J Pediatr 

Otorhinolaryngol 2001; 58:89-90. 

7. Tsai CH, Hsu M-C, Liu C-M.Sphenochoanal 

polyp.Tzu Chi Med J 2008; 20:223-6. 

8. Berg O, Carenfelt C, Silfversward C. Origin of 

the choanal polyp. Arch Otolaryngol Head Neck 

Surg 1988; 114:1270-1. 

9. Mils CP. Secretory cysts of the maxillary antrum 

and their relation to the development of antrochoanal 

polyp. J Laryngol Otol 1959; 73:324-34. 

10. Cook PR, Davis WE, Mc Donald R, Mc Kinsey 

JP. Antrochoanal polyposis: a review of 33 cases. 

ENT J 1993; 72:401-10. 

11. Crampette L, Mondain M, Rombaux P. Sphenochoanal 

polyp in children. Diagnosis and treatment. 

Rhinology 1995;33:43-5. 

12. Weissman JL, Tabor BK, Curtin HD. Sphenochoanal 

polyps:evaluation with CT and MR imaging. 

Radiology 1991;178:145-8. 

13. Soh KBK, Tan KK. Sphenochoanal polyps in Singapore: 

diagnosis and current management. Singapore 

Med J 2000; 41:184-7. 

14. Yanagisawa E, Yanagisawa K. Endoscopic view 

of thornwald cyst of the nasopharynx. Ear Nose 

Throat J 1994; 73:884-5. 

15. Bozzo C, Garrel R, Meloni F, Stomeo F, Crampete 

L. Endoscopic treatment of antrochoanal polyps. 

Eur Arch Otorhinolaryngol 2007; 264:145-50. 

273

274 


CASE REPORT 

Primary extranodal Natural Killer/ 

T-cell lymphoma of the ethmoid 

sinus masquerading as orbital 

cellulitis 

Davorin \anić1 , Ana \anić Hadžibegović1 , Ivana 

Mahovne2 1Department of Otorhinolaryngology, Head and Neck Surgery, 

2Department of Pathology; General Hospital Slavonski Brod, 

Slavonski Brod, Croatia 


Davorin \anić, 

Department of Otorhinolaryngology, Head and Neck Surgery 

General Hospital Slavonski Brod, A. Štampara 42, 

35 000 Slavonski Brod, Croatia 

Phone/ Fax: +385 35 446 177 

E-mail: davorin.djanic@sb.t-com.hr 

Original submission: 29 January 2009; Revised submission: 

14 April 2009; Accepted: 22 April 2009. 

Med Glas 2009; 6(2): 274-277 

ABSTRACT 

This report presents a case of an exceptionally 

rare primary Natural Killer/T cell (NK/T) lymphoma 

of the right paranasal frontal and ethmoid 

sinuses in a patient treated previously for right 

side chronic sinusitis. It highlighted the importance 

of adequate tissue biopsy and patohistological 

examination in patients with chronic sinusitis 

or orbital cellulitis that fail to respond to 

traditional management. 

Key words: NK/T cell lymphoma, paranasal sinuses 

INTRODUCTION 

In 1897 Mc Bride first described a patient with 

surface crusting, widespread necrosis and inflammation, 

aggressive and rapid destruction of nose 

and face midline, and lethal course (1). In the past, 

the term “lethal midline granuloma” was usually 

used but it included three histologically different 

lesions: Wegener’s granulomatosis, polymorphic 

reticulosis and malignant lymphoma (2). 

Neoplasms of paranasal sinuses are very rare, 

comprising less than 3% of all autodigestive tract 

tumors (3). Lymphoma of the primary paranasal 

sinuses are even rarer and represent only 0-17% 

of all lymphomas in Kiel Lymph Node registry 

and account for only 5-8% of the extranodal lymphomas 

of the head and neck area (3). 

Based on morphology and cell lineage there 

are currently 3 types of lymphoma: B cell, T cell 

and Hodgkin lymphoma. In addition, many proliferating 

T cells have shown to express an additional 

marker (CD56), which suggests an NK 

cell origin. These tumors are classified as NK/T 

lymphomas (4). 

Most common presenting signs and symptoms 

of primary paranasal sinuses lymphoma 

are nonspecific and fall into several categories: 

nasal: epistaxis, nasal obstructions, congestion, 

extension into the nasal cavity; facial: unilateral 

facial or cheek swelling, facial asymmetry, pain, 

infraorbital nerve hypoesthesia; and ocular: unilateral 

tearing, diplopia, fullness of lids, pain, and 

exophthalmia (5). 

In this paper we presented an uncommon 

case of primary NK/T lymphoma of the ethmoid 

sinus masquerading as chronic rhinosinusitis and 

orbital cellulitis. 

CASE REPORT 

A 60 year-old man presented with progressive 

well marked periorbital edema and erythema 

of the right eye, and thickness of the nasal dorsum 

and right cantal region. During the last 5 

years he had been treated for right side chronic 

sinusitis. He had six millimeters proptosis and 

relative upper eyelid ptosis of the right eye. Nasal 

endoscopy revealed anterior deviation of nasal 

septum, obstructed ostiomeatal complex with a 

black mass and purulent discharge in the middle 

and common meatus. 

Computed tomography (CT) scan of the 

paranasal sinuses and orbit showed soft tissue 

mass filling the right ethmoid, frontal and maxillary 

sinus, eroding the anterior part of the right 

lamina papiracea, and infiltrating right medial 

rectus muscle (Figure 1). Retention cyst in max-

illary sinus, polypoid mucosa of ethmoid sinuses 

and orbital soft tissue swelling without focal abscess 

were found during a functional endoscopic 

surgery. All of necrotic tissue was removed and 

first histological examination showed chronic 

inflammation of paranasal sinusal mucosa. Bacterial 

and fungal cultures were negative. Four 

months later the patient developed fever, swelling, 

surface crusting, and widespread necrosis 

of the right periorbital and nasal area (Figure 2). 

Multiple biopsies of the paranasal sinuses were 

performed and diagnosed as nonspecific granulomatous 

inflammation. 

Finally, diagnosis of NK/T cell (CD 56+) 

lymphoma was made by histological and imunohistochemical 

reexamination of the paraffineembeded 

tissue obtained from the first biopsy of 

the ethmoid sinus and orbit. There were necrotic 

changes of varying degrees and a polymorphous 

pattern of proliferation involving large atypical 

cells with an occasional multilobated nucleus and 

various numbers of lymphocytes, plasma cells 

and macrophages. Features of vascular invasion 

by neoplastic lymphocytes were apparent. Occasionally, 

angiocentric pattern of proliferation was 

observed. Large atypical cells were positive for 

the NK-cell marker CD 56 (Figure 3). Patient had 

IV-A stage lymphoma and was EBV positive. 

Neck lymph nodes were negative. Thoracic 

and abdominal CT scans as well as bone marrow 

biopsy were all negative. He was scheduled for 

continuous chemotherapy with 8 CHOP 14-day 

Figure 1. Axial CT scan showing soft tissue mass in the right 

ethmoid, frontal, and maxillary sinus eroding bony structures 

and infiltrating right medial rectus muscle (D. \anić, 2007.) 

Case report 

cycles. Unfortunately, the patient’s condition 

deteriorated rapidly after the development of 

liver failure and respiratory failure and after 18 

months he died. 

Primary paranasal sinus NK/T-cell (CD 56 

positive) lymphoma is a polymorphic extranodal 

lymphoma, expressing NK or rarely cytotoxic Tcell 

phenotype (3). It is an uncommon disease, and 

generally highly aggressive in its clinical course. 

Primary paranasal sinus T-cell lymphomas are 

much more frequent in Asian and Latin American 

countries, present at younger age, and usually 

arise from nasal cavity than the paranasal sinuses. 

In contrast, lymphomas of B-cell phenotype predominate 

in Western population and usually arise 

from paranasal sinuses. T-cell lymphomas are 

characterized by progressive ulceration and necrosis 

that are not typical for B-cell lymphomas (3, 5). 

Numerous studies showed that patients with NK/T 

lymphomas of the sinusonasal area had a high incidence 

of Epstein-Barr virus infections (6). 

The majority of lymphomas involving the 

ocular adnexa are of B-cell lineage. However, 

NK/T- cell lymphoma is associated only infrequently 

with orbital or adnexal involvement (7). 

Life style and environmental factors significantly 

increased risk for developing NK/T-cell lymphoma 

among individuals exposed to pesticides (8). 

Figure 2. Widespread necrosis of the right periorbital and 

nasal area in a patient with primary paranasal NK/T-cell 

lymphoma (D. \anić, 2007., with patient’s permission) 

275

276 


This patient lived in a rural area, worked in agricultural 

environment and was exposed to pesticides 

for many years. 

The diagnosis of lymphoma cannot be made 

from clinical findings solely and thus biopsy and 

imaging of the lesions is mandatory prior to any 

treatment (9). During the diagnostic procedure 

adequate tissue biopsy must be taken to differentiate 

lymphoma from destructive inflammatory 

diseases or malignant tumors (9). Biopsy must be 

adequate, not too small or too superficial because 

sinusonasal lymphomas are subepithelial lesions, 

often with perfectly normal overlying mucosa, 

unlike carcinoma, which are usually ulcerative 

(9). Repeated biopsy may sometimes be needed. 

Cross-sectional imaging findings like pathologic 

contrast enhancement or bone changes may reveal 

the malignant nature of the disease but there 

is significant overlapping between those possible 

pathologies that can arise in this region (9). Physiologic 

imaging, like perfusion CT and proton 

MR spectroscopy, in the extracranial head and 

neck can be implemented in any CT or MRI survey, 

provide functional information of the lesion, 

and may be helpful to differentiate benign from 

malignant disease as well as guide therapeutic 

decisions (10). 

The optimal treatment for primary nasal lymphoma 

remains unknown (11). Surgical resection 

of paranasal sinusal lymphoma is not recommended 

unless the tumor spreads to critical locations 

resulting in impending death (11). Complete 

response rate after radiotherapy is much higher as 

compared to chemotherapy although radiothera- 

Figure 3. Immunohistological section of the lymphoma showing 

strong positive staining for cytoplasmic CD56 (CD56; x40) 

(I. Mahovne, 2007.) 

py planning for primary nasal lymphomas may 

be difficult because these lymphomas often encroach 

on such radiosensitive critical structures 

as the optic chiasm, optic nerve and eyeballs and 

exact dose-tumor response relationship is unknown 

(11). Addition of chemotherapy to radiotherapy 

did not improve survival rate with early 

stage NK/T cell lymphoma (12). Ocular manifestation 

prior to systemic ones may be useful to 

monitor the response to therapy (12). 

Prognosis associated with sinonasal NK/T 

cell lymphomas varies. Dissemination is infrequent, 

but when it occurs it typically involves 

other extranodal sites (12). 

In conclusion, this case highlights the importance 

of adequate tissue biopsy and patohistological 

examination in patients with chronic 

sinusitis or orbital cellulitis that fail to respond to 

traditional management. 



REFERENCES 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

McBride P. Photographs of a case of rapid destruction 

of the nose & face. Laryngol 1987;12:64–6. 

Kassel S, Echevaria RA, Guzzo FP. Midline malignant 

reticulosis (so-called lethal midline granuloma). 

Cancer 1969;23:920–35. 

Aozasa K, Takakuwa T, Hongyo T, Yang WI. 

Nasal NK/T-cell lymphoma: epidemiology and 

pathogenesis. Int J Hematol 2008; 87:110-7. 

Swerdlow SH, Campo E, Harris NL, Jaffe ES, 

Pileri SA, et al. WHO Classification of Tumours, 

Volume 2 [IARC WHO Classification of Tumours, 

No 2], 2008. 

Vidal RW, Devaney K, Farkiti A, Rinaldo A, 

Carbone A. Sinusonasal malignant lymphomas: 

a distinct clinicopathological category. Ann Otol 

Rhinol Laryngol 1999; 108:411-449. 

Van de Rijin M, Bhargava V, Molina-Kirsc H, 

Carlos-Bregni R, Warnke RA, Cleary ML. Extranodal 

head and neck lymphomas in Guatemala: 

high frequency of Epstein-Barr virus associated 

sinusonasal lymphomas. Hum Pathol 1997; 

28:834-9. 

Charton J, Witherspoon SR, Itani K, Jones FR, 

Marple B, Morse B. Natural Killer/T –cell lymphoma 

masquerading as orbital cellulitis. Ophtal 

Plast Reconst Surg 2008; 24:143-5. 

Hardell L, Erickson MA. A case-control study of 

non-Hodgkins lymphoma and exposure to pesticide. 

Cancer 1999; 85:1353-60.

9. Chen SH, Wu CS, Chan KH, Hongh YT, Shun 

CT, Liu CM. Primary sinusonasal non-Hodgkins 

lymphoma masquerading as chronic rhinosinusitis: 

an issue of rutine histopathological examination. 

J Laryngol Otol 2003; 117:404-7. 

10. Bisdas S, Fetscher S, Feller AC, Baghi M, Knecht 

R, Gstoettner W, Vogl TJ, Balzer JO. Primary B 

cell lymphoma of the sphenoid sinus: CT and 

MRI characteristics with correlation to perfusion 

and spectroscopic imaging features. Eur Arch 

Otorhinolaryngol 2007; 264:1207-13. 

11. Yu K. Primary nasal lymphoma. J HK Coll Radiol 

2001; 4:128-32. 

12. Yao B, Song YW, Jin J, Wang WH,Wang SL Sun 

YT et al. Treatment option and outcome for patients 

with primary non-Hodgkins lymphoma of 

the nasal cavity. Zhonguhua Zhong Liu Za Zhi 

2006; 28:58-61. 

CASE REPORT 

Knee disarticulation 

Ognjen Živković¹, Antun Muljačić², Renata Poljak- 

Guberina³ 

¹Institute for Rehabilitation and Orthopaedic Aids of the University; 

Hospital Center, Zagreb, ²University Hospital of Traumatology, 

Zagreb, ³Private Practice, Zagreb; Croatia 


Renata Poljak–Guberina 

Private practice 

Rockefellerova 23a, 10000 Zagreb, Croatia 

Phone: +385 1 481 7705 

E-mail: renata.poljak@zg.t-com.hr 

Original submission: 16 September 2008; Revised submission: 

29 December 2008; Accepted: 04 February 2009. 

Med Glas 2009; 6(2): 277-279 

ABSTRACT 

In this paper we presented three patients with 

knee disarticulation performed according to 

Baumgartner. The Baumgartner tehnique and the 

application of knee disarticulation prosthesis appeared 

to be superior in comparisson with other 

methods. 

Key words: knee, disarticulation, Baumgartner 

tehnique 

INTRODUCTION 

Knee disarticulation is a rarely used method 

in amputation surgery, primarily due to the operative 

technique itself and secondly, due to poor 

Case report 

understanding of prosthetic replacement possibilities 

(1). Technological progress and new developments 

in the prosthetics have opened new 

possibilities of amputation methods and consequently 

in the choice of the amputation level (1). 

A prosthesis for patients with knee disarticulation 

has been designed, with construction being based 

on the operative method of knee disarticulation 

according to Baumagartner (2). The energy expenditure 

during walking with knee disarticulation 

prosthesis is a little more than 40%, the same 

as for below-knee prosthesis (3). 

Disarticulation of a knee is recommended for 

high traumatic amputation of the below-knee, crush 

injury, complex injuries and tumors of the belowknee 

(1). Surgeons have been in dilemma between 

the method of transcondylar amputation and knee 

disarticulation (2). Knee disarticulation proves to 

be superior due to the possibilities of prosthetic replacement. 

The advantages are: a long and strong 

stump with a tip that can endure full-weight bearing 

and is suitable for a knee disarticulation prosthesis, 

the energy expenditure during walking equal to 

walking with below-knee prosthesis, normal function 

of the abbove-knee muscles (2). Unpopularity 

of knee amputation over many years was caused 

by bad experience with primary wound healing and 

the resulting stump of poor quality with regard to 

its function (2). In order to prevent these complications 

some surgeons introduced modifications in 

operative method (4-6). These methods are surgically 

more demanding and associated with a higher 

risk of complications (7). 

Baumgartner 1971 describes the method of 

knee disarticulation as a surgically simple procedure 

that creates a functionally satisfactory stump 

with regard to further prosthetic fitting (2). The 

simplicity of the technique is reflected in every 

aspect - skin, cartilage, bone, muscles (2). 

During the last 10 years the Clinic of Traumatology 

Zagreb has been using the technique of 

knee disarticulation described by Baumgartner. 

However, we have introduced some minor modifications. 

Instaed of sutturing the patellar ligament 

as Baumagartner was practising, we cut ligament 

at the top of the patella. So we additionally 

increas the contact and weight-bearing surface 

277

278 


of the stump. These modifications have yielded 

good results in the application of disarticulation 

prosthesis for the knee. 

Three patients (of different age but with the 

same successful therapy results) with knee disarticulation 

performed are presented in this study 

( Figure 1). 

A skin incision is performed in two directions 

from the outer side of the medial and lateral condyle 

using an anterior long semicircular incision 

at 3-5 cm distally below the tibial tuberosity and 

posteriorly at the level of the sagittal line along 

the midline of the popliteal fossa – Procedure I . 

A skin flap is raised and the knee joint exposed. 

The exposed collateral ligaments and hamstring 

tendons are resected . The patellar ligament is 

cut off at the patellar tip. The patella is placed in 

the position of “patella alta”, which additionally 

increases the contact and weight-bearing surface 

of the stump. A transverse wide capsulotomy is 

done to expose the knee joint with menisci and 

ACLs that are resected -Procedure II . The knee 

joint is flexed, the notch is exposed, the PCL is 

removed and the femoral condyle surface is left 

intact. Nerves and blood vessels in the popliteal 

fossa are exposed, ligated and transsected. Intact 

cartilage and femoral condyles are covered with 

the anterior skin flap which is sutured tension - 

free to the posterior skin flap in the popliteal fossa 

– Procedure III . A free drain is placed below the 

fascia along the entire scar length. The drain is removed 

after two days and sutures after 14 days. 

Case one: A 61-year-old male patient fell 

under a motor excavator and a distal third of the 

right below-knee was crushed. Primary amputation 

at the level of the middle third of the belowknee 

was performed. The wound was left open 

and local therapy instituted. Due to complications 

in terms of bone protrusion on the fibular 

and tibial stumps, musculo-cutaneous defect and 

impossibility of wound closure, reamputation at 

the proximal third level was indicated. Knee disarticulation 

was done and after the wound healing 

the patient was admitted to the rehabilitation 

and fitted with a disarticulation prosthesis. After 

the prosthetic rehabilitation the patient was able 

to use the prosthesis during the whole day, walk 

independently, use a walking cane for longer 

walks and work on the land. 

Case two: A 36-year-old male patient substained 

a traumatic amputation of distal third of 

the right below-knee, and a femoral fracture due 

to a mine explosion. Transtibial amputation was 

performed at the level of the proximal third and 

the right femur was treated by internal fixation according 

to the AO method. After several months 

of treatment, the stump was in flexion contracture 

greater than 30 degrees. Prosthetic fitting was not 

possible so surgeon recommended the knee disarticulation. 

After the completed healing of the stump, 

prosthetic rehabilitation began. Following rehabilitation 

the patient was able to use the prosthesis for 

all daily activities and to walk unassisted. 

Case three: A 45-year old male patient was 

injured in a traffic accident as a car driver and 

substained an open fracture of the right belowknee. 

An operative treatment of this complex 

fracture was attempted but due to infection appearing 

in the postoperative course the amputation 

was indicated. The knee disarticulation was 

performed and prosthetic rehabilitation began 

(Figure 2). After a rehabilitation the patient wore 

the prosthesis during the entire day, used a walking 

cane for longer walks and worked actively. 

According to American authors, knee dis- 

Figure 1. Modified technique of knee disarticulation by Baumgartner 

(R. Poljak–Guberina, 2004., with patient’s permission)

articulation is described as a simple, safe operative 

procedure, which has advantages in the 

prosthesis application but which is not widely 

applied (8). Some authors recommend the Mazet 

and Hennessy as well as the Burgess or Bowker 

methods (5,9) . For those methods it is significant 

that due to cartilage removal a large bone surface 

is created, which increases the risk for bleeding 

and consequently associated complications (5). 

Thus, the end-bearing of the distal stump portion 

is significantly reduced. In the prosthetic sense, a 

disarticulation stump of the knee is obtained and 

it can accept only an above-knee prosthesis with 

weight-bearing tuberosity of the ischial bone. 

This is the very reason for application of those 

methods only for palliative indications where no 

prosthesis will be applied because patients will 

use wheel chairs (8). However, according to the 

International Society for Prosthetics and Orthotics 

(ISPO) Consensus Conference on Amputation 

Surgery 1990, knee disarticulation has an 

absolutely important place in the practice as an 

amputation technique (10). It is recommended in 

younger and elderly patients with indications like 

trauma, tumors, below-knee infections or circulatory 

problems in diabetics (11). 

Our ten-year experience (150 transcondylar 

amputations and 15 knee disarticulations) of the 

application of knee disarticulation as well as the 

application of the disarticulation prosthesis for 

the knee shows the advantage of this technique 

in relation to transcondylar amputation of the 

femur. Our patients with knee-disarticulation 

prosthesis showed in average a 50% increase 

in walking speed in comparison with patients 

with above-knee prosthesis. Our conclusions are 

Figure 2. Knee-disarticulation stump and prostheses (R. 

Poljak–Guberina, 2004., with patient’s permission) 

equivalent with results of authors that showed 

that energy consumption during walk with disarticulation 

prosthesis was increased by 40% and 

with the above-knee prosthesis by 70 – 80% (3). 

The advantages of knee-disarticulation are the 

simplicity of operative procedures, good quality 

of stump and successfully application of prosthesis 

which result in inproved quality of life. 


Written consent was obtained from the patient 

for publication of the Figure 1 and Figure 2. 

REFERENCES 

Case report 

1. Murdoch G, Bennett WA, Jr. Amputation- Surgical 

practice and patient management. Oxford: 

Butterworth-Heinemann Co, 1996. 

2. Baumgartner RF. Knee disarticulationem versus 

above-knee amputation. Prosthet Orthot Int 1979; 

3:15-9. 

3. Nader M, Nader HG. Otto-Bock prosthetic compendium: 

lower extremity prostheses. Berlin: 

Schiele and Schon GmbH., 2002. 

4. Faber David C, Fielding P. Gritti-Stokes 

(Through-Knee) amputation: should it be reintroduced? 

South Med J 2001; 94:997-1001. 

5. Mazet R, Hennessy CA. Knee disarticulation: a 

new technique and a new knee joint mechanism. J 

Bone Joint Surg 1966; 48:126-39. 

6. Vaucher J, Blanc Y. Les desarticulation du genou. 

Technique operatoire-appareillage (Disarticulation 

of the knee. Surgical and prosthetic techniques.) 

Rev Chir Orthop1982; 68:385-406. 

7. Duerksen F, Rogalsky RJ, Cochrane IW. Knee 

disorticulation with intercondylar patellofemoral 

arthrodesis. Clin Orthop1990; 256:50-6. 

8. Smith DG, Micheal JW, Bowker JH. Atlas of Amputations 

and Limb Deficiencies: Surgical, Prosthetics, 

and Rehabilitation Principles. American 

Academy of Orthopeadics Surgeons, Rosemont, 

Illinois, 2004. 

9. Murdoch G, Bennett WA, Jr. A primer on amputations 

and arteficial limbs. New York: Charles 

Thomas Co., 1998. 

10. Jensen SJ, Lyquist E: Through-knee amputations. 

International Society for Prosthetics and Orthotics 

( ISPO) Consensus Conference on Amputation 

Surgery. University of Strathclyde, Dundee, 

Scotland, 1990: 69-81. 

11. DL, Taylor SM, Hamontree SE, Langan EM, 

Snyder BA, Sullivan TM, Youkey JR. A reappraisal 

of a modified through-knee amputation in 

patients with peripheral vascular disease. Am J 

Surg 2001;182:44-8. 

279

280 


CASE REPORT 

Izvanmaternična trudnoća 

izliječena metrotreksatom 

Ljiljana Bilobrk Josipović, Branka Lovrinović, 

Anton Galić 

Ginekološko-porođajni odjel, Hrvatska bolnica “Dr. Fra Mato 

Nikolić”, Nova Bila, Bosna i Hercegovina 


Ljiljana Bilobrk Josipović, 

Ginekološko-porođajni odjel, Hrvatska bolnica “Dr. Fra Mato 

Nikolić”, Dubrave bb, 72276 Nova Bila, Bosna i Hercegovina 

Phone: +387 33 200 518; Fax.: +387 33 200 518 

Email: bjljiljana@hotmail.com 

Originalna prijava: 19. mart 2009.; Korigirana verzija: 20. april 

2009.; Prihvaćeno: 06. maj 2009. 

Med Glas 2009; 6(2): 280-283 

SAŽETAK 

Prikazan je slučaj pacijentkinje čija je tubarna 

trudnoća liječena medikamentozno, metrotreksatom. 

Pacijentkinja se, 10+1 tjedan po izostanku 

menstruacije, javila ginekologu zbog blažih bolova 

pri dnu trbuha i oskudnog vaginalnog krvarenja. 

Pregledom, ultrazvučno i biokemijskim 

biljezima, dijagnosticirana je izvanmaternična 

(tubarna) trudnoća u desnom jajovodu. Početna 

razina β hCG-a bila je 5005 mIU/ml, a veličina 

gestacijskog miješka 51 x 47 mm, sa embrijem 

dužine 5 mm. Pacijentkinja je uspješno izliječena 

jednom ampulom metrotreksata od 50 mg, koja 

je aplicirana intramuskularno. 

Ključne riječi: izvanmaternična trudnoća, 

metrotreksat, vrijednosti β hCG-a 

Uvod 

Izvanmaternična ili ektopična trudnoća jeste ona 

trudnoća koja se implantira i razvija izvan šupljine 

maternice. Najčešće je smještena u jajovodu (97%), 

ali može biti i u ovariju, trbušnoj šupljini, atretičnom 

rogu maternice, grliću i u plica lata (1). Kod tubarne 

trudnoće zametak je najčešće smješten u ampuli, 

poslije toga u istmičnom dijelu jajovoda, abdominalnom 

ušću, fimbrijama i intersticijskom dijelu jajovoda 

(1). Poseban slučaj predstavlja heterotopična 

trudnoća koja podrazumijeva istovremeno i 

unutarmaterničnu, i izvanmaterničnu trudnoću (2). 

Glavni klinički simptomi ektopične trudnoće su 

izostanak menstruacije, bol u trbuhu i vaginalno 

krvarenje (3). Dijagnosticira se ginekološkim i 

ultrazvučnim pregledom, biokemijskim biljezima 

(β hCG, estriol, progesteron), kiretažom maternice 

i kuldocentezom (3). Određivanje kreatinin kinaze 

i onkofetalnog fibronektina, kao biokemijskih 

biljega izvanmaternične trudnoće, je napušteno 

(4, 5). Danas je uobičajena vaginalna sonografija i 

Doppler u boji, u kombinaciji sa određivanjem razine 

β hCG-a (6, 7, 8). 

Izvanmaterničnu trudnoću uobičajeno je 

liječiti kirurški, laparoskopijom ili laparotomijom, 

poslije čega uslijedi salpingektomija ili 

rjeđe salpingotomija. Laparoskopija je, u zadnje 

vrijeme, češći pristup zbog brojnih prednosti 

pred laparotomijom (9). Relativne kontraindikacije 

jesu prethodni operativni zahvati, odnosno 

priraslice u trbuhu, tubarna trudnoća, veća od 

6 cm i β hCG veći od 5.000 mIU/ml. Ponekad 

se primjenjuje i kombinirana laparoskopskofarmakološka 

metoda (9). 

Manji broj pacijentkinja vodi se ekspektativno 

ili medikamentozno. Uvjeti za medikamentozni postupak 

su nerupturirana izvanmaternična trudnoća 

manje od 4 cm, isključena heterotopična trudnoća, 

vrijednost β hCG ≤ 5.000 mIU/ml (po nekim autorima 

≤ 3.000 mIU/ml), vrijednost progesterona 

manja od 40 nmol/L i hemodinamski stabilna pacijentkinja 

(10). U medikamentoznom liječenju mogu 

se primijeniti metrotreksat, aktinomicin D, NaCl, 

hipertonička otopina glukoze (50%), prostaglandini 

E i F i mifepriston (10). Osim tubarne trudnoće, 

2 2α 

medikamentozno se najčešće liječe cervikalna i intersticijska 

trudnoća (10). U kliničkoj primjeni uglavnom 

se koristi metrotreksat (11). 

U ovom radu prikazali smo slučaj uspješnog 

medikamentoznog liječenja tubarne trudnoće 

metotreksatom. 


Tridesetogodišnja pacijentkinja primljena je 

na Ginekološko-porođajni odjel Hrvatske bolnice 

“Dr. Fra Mato Nikolić” zbog krvarenja i bolova 

u trbuhu koji su počeli dva dana ranije, s amenorejom 

10 +1 tjedan, hemodinamski stabilna pri prijemu. 

Iz reproduktivne anamneze pacijentkinja 

je navela dva poroda (prvi završen vaginalno;

drugi operativno, carskim rezom, zbog parcijalne 

abrupcije posteljice tijekom poroda), jedan spontani 

pobačaj u 8. tjednu trudnoće, menstrualni 

ciklusi 30/5. Od ranijih oboljenja, pacijentkinja 

je imala česte vaginalne infekcije, a povremeno 

infekcije mokraćnog sustava. Obiteljska anamneza 

bila je bez osobitosti. Ginekološkim nalazom 

ustanovljeno je slijedeće: cilindričan grlić, dužine 

dva članka prsta, uz zatvoreno vanjsko ušće; krvarenje 

ex utero u tragu oskudnim tamnocrvenim 

iscjetkom; uterus, veličine guščijeg jajeta, mekše 

konzistencije, desno adneksalno kobasičasta tumefakcija, 

palpatorno bolno osjetljiva; lijeva adneksa 

i parametrija urednog palpatornog nalaza, 

Douglasov prostor slobodan. 

Transvaginalnim kolor-doplerom (TVCD) 

ustanovljeno je slijedeće: uterus 62 x 62 x 36 mm; 

endometrij 12,6 mm, inhomogen, bez vidljive 

intrauterine trudnoće; desni ovarij 35 x 23 mm, 

a ispod desnog ovarija inhomogena izdužena 

struktura sa gestacijskim miješkom 51 x 47 mm, 

embrionalni odjek 5 mm, bez vidljivih srčanih 

otkucaja; uz rub gestacijskog miješka, obilan 

protok sa RI: 0,667; lijevi ovarij 21,7 x 21,8 mm, 

bez vidljive slobodne tekućine u abdomenu. 

Uz informirani pristanak, pacijentkinji se, isti 

dan po prijemu, ordinira 50 mg metrotroksata intramuskularno, 

te intravenski (i.v.) 80 mg garamycina, 

dva puta dnevno (cave penicillin), 500 mg 

metronidazola, tri puta dnevno, po 500 ml ringer 

solutio i 5% glukoze jedanput dnevno. Drugi dan 

Case report 

Slika 1. Ultrazvučni nalaz pacijentkinje: maternica i desni 

jajnik (izvanmaternična trudnoća u desnom jajovodu) kod 

prijema (lijevo); maternica i desni jajnik, devet mjeseci nakon 

liječenja (desno) (Ginekološko-porođajni odjel, HB “Dr. fra 

Mato Nikolić” Nova Bila, BiH, 2008.) 

po prijemu, pacijentkinji se peroralno ordinira 

folacin od 5 mg 3 x 2. Leucovorin (kalcij folinat) 

ampule nismo uspjeli pronaći u ljekarnama. 

Trećeg dana hospitalizacije pacijentkinja 

se žali na nešto intenzivnije bolove u trbuhu. 

Ultrazvučno je uočena oskudna količina tekućine 

u Douglasovom prostoru. Pošto je pacijentkinja i 

dalje bila hemodinamski stabilna, nastavljeno je 

praćenje, te su bolovi prestali slijedeći dan. Pacijentkinja 

je otpuštena sedmog dana po prijemu, sa 

zadovoljavajućim vrijednostim β hCG i krvne slike 

(Tablica 1), veličine gestacijskog miješka od 10,7 x 

16,7 mm, bez vidljive slobodne tekućine u trbuhu. 

Ginekološki nalaz kod otpusta bio je slijedeći: grlić 

maternice cilindričan, bez vaginalnog krvarenja, 

maternica veličine guščijeg jajeta, tvrde konzistencije; 

desna adneksa i parametrija zadebljana za 

veličinu od jednog poprečnog prsta; lijeva adneksa 

i parametrija uredna. Iz bakteriološke kulture cervikalnog 

brisa, izoliran je Streptococcus foecalis i 

Neisseria gonorrhoeae, poslije čega je uključena i 

antibiotska terapija po antibiogramu. 

Dani nakon početka liječenja 

Vrijednosti parametara* Kod prijema 2. dan 3. dan 5. dan 7. dan 10. dan 30. dan 

β hCG (mIU/mL) 5005 1925 922 310 89 1,2 

Er (1012 /L) 4,19 4,13 3,58 3,45 3,69 

Hb (g/L) 133 133 114 111 119 

Hct ( L/L) 0,37 0,37 0,32 0,31 0,33 

Le (109 /L) 8,7 4,3 

Tr (109 Tablica 1. Vrijednosti laboratorijskih parametara kod prijema i tokom liječenja 

/L) 170 154 132 118 163 

MCV (fL) 89 

MCH (pg) 32 

MCHC (g/L) 352 

Fibrinogen (g/L) 5,1 

Se (mm/h) 14 

CRP (mg/dL) 24 

Urea (mmol/L) 2,3 

Kreatin (µmol/L) 53 

Ukupni bilirubin(µmol/L) 12 

AST (U/L) 70 43 28 

ALT (U/L) 26 19 19 

GGT (U/L) 10 

Alkalna fosfataza (U/L) 36 

*β hCG, β humani korionski gonadotropin; Er, eritrociti; Hb, hemoglobin; Hct, hematokrit; Le, leukociti; Tr, trombociti; MCV, mean corpuscular 

volume; MCH, mean corpuscula hemoglobin; MCHC, mean corpuscular hemoglobin concentration; Se, sedimentacija, CRP, C reaktivni protein; 

AST, aspartat aminotransferaza; ALT, alanin aminotransferaza; GGT, gamma glutamiltransferaza 

281

282 


Desetog dana, nakon započetog liječenja 

(ambulantno), vrijednost β hCG iznosila je 89 

mIU/ml, a nakon mjesec dana 1,2 mIU/ml (Tablica 

1), što je ukazivalo na uspješnost primjenjenog 

liječenja koje nije imalo nikakvih posljedica 

po zdravlje pacijentkinje. 

Šest mjeseci poslije sprovedene terapije, 

nije ustanovljena prisutnost β hCG (0 mIU/m). 

Palpatorno je ustanovljena diskretna osjetljivost 

desnih adneksa i parametrija, a ultrazvučna slika 

maternice i jajnika bila je uredna, bez vidljivog 

proširenja desnog jajovoda. Pacijentkinji je 

predložena histerosalpingografija, koju ona odbije 

jer nije planirala dalje trudnoće. 

Ponovljeni palpatorni i ultrazvučni pregled, 

devet mjeseci nakon liječenja, ostao je isti. 

Transabdominalnim ultrazvukom moguće je 

dijagnosticirati izvanmaterničnu trudnoću kod vrijednosti 

β hCG 5000 – 6000 mIU/mL, a transvaginalnim 

ultrazvukom kod vrijednosti β hCG-a 1000 

– 1500 mIU/mL (12). Medikamentozno liječenje 

ektopične trudnoće u svijetu je čest postupak. Po 

jednoj shemi metrotreksat se daje u četiri doze, 

prvi, treći, peti i sedmi dan, a leucovorin drugi, 

četvrti, peti i osmi dan. Po drugoj shemi, daje se 

50 mg metrotreksata intramuskularno jednokratno 

(12). Ista doza lijeka može se ponoviti, ako 

se vrijednost β hCG ne snizi za l5% od početne 

vrijednosti za sedam dana, do ukupno četiri doze. 

β hCG se određuje svaki tjedan do negativizacije 

nalaza. Potpuna negativizacija β hCG-a očekuje se 

za 4-6 tjedana. Najmanje tri mjeseca iza primjene 

metrotreksata, treba odgoditi slijedeću trudnoću 

(12). Mi smo primijenili drugu shemu, bez potrebe 

ponovnog davanja lijeka za sedam dana. 

U nekim studijama daje se prednost medikamentoznom 

načinu liječenja pred kirurškim postupcima 

i to kod pacijentkinja koje zadovoljavaju 

kriterije za medikamentozno liječenje (13, 14). 

Medikamentozno liječenje je svakako manje 

traumatičan, jeftiniji i jednako uspješan način 

liječenja u slučajevima kada je izvanmaternična 

trudnoća dijagnosticirana na vrijeme. U jednoj 

studiji, koja je obuhvatila 350 pacijentkinja, 

ovaj način liječenja bio je uspješan kod 92% 

pacijentkinja, sa vrijednostima β hCG manjim 

od 5.000 mIU/mL, a uspješnost je bila 98% sa 

vrijednostima β hCG manjim od 1.000 mIU/ 

mL (15). Smatra se i da je u većini slučajeva dovoljna 

jednokratna primjena metrotreksata (16). 

Kombinirana primjena metroksata i mifepristona 

povećava uspjeh terapije (17). 

U našem radu prikazan je slučaj pacijentkinje 

sa uspješno izliječenom tubarnom trudnoćom 

metrotreksatom. Međutim, metrotreksat je 

uključen pri “nešto većoj” vrijednosti β hCG-a 

i pri “znatno većoj” dimenziji gestacijskog 

miješka od preporučenih (10). Razlozi zbog kojih 

smo se odlučili za medikamentozno liječenje kod 

naše pacijentkinje bili su prethodni operativni zahvat 

(carski rez), neobučenost ginekologa za endoskopske 

kirurške zahvate, hemodinamska stabilnost 

bez vidljivog krvarenja u trbuh. Trećega 

dana hospitalizacije, registrirana je kratkotrajna 

bol u trbuhu zbog manjeg istjecanja hemoragičnog 

sadržaja iz jajovoda u Douglasov prostor, što 

je dijagnosticirano ultrazvučno. Vrijednosti β 

hCG-a pokazivale su kontinuirani pad što ne mora 

biti uobičajeno kod ove terapije (12). Ponekad se 

može pojaviti i kratkotrajno povećanje vrijednosti 

β hCG-a, između 3. i 5. dana liječenja, što ne mora 

biti razlog za hitnu kiruršku intervenciju, ako je 

pacijentkinja hemodinamski stabilna i bez većeg 

pada vrijednosti hemograma (12). Naša pacijentkinja 

bila je pod intenzivnim bolničkim nadzorom 

sedam dana od postavljanja dijagnoze, nakon 

čega je otpuštena na kućno liječenje uz redovite 

kontrole. Od očekivanih nuspojava razvila se 

kratkotrajna neutropenija i trombocitopenija, kao 

i kratkotrajno povećanje vrijednosti transaminaza, 

zbog primjene citostatika (11). Nakon mjesec 

dana, uključena je i dodatna antibiotska terapija 

zbog dijagnosticirane kontaminacije cervikalne 

sluznice bakterijama. Infekcije adneksa najčešće 

nastaju ascendentnim putem, mada se ne može 

isključiti ni mogućnost hematogenog, limfogenog 

širenja infekcije ili perkontinuitatem (12). 

Palpatorni i ultrazvučni nalaz desnih adneksa, 

nakon šest mjeseci, bio je zadovoljavajući, 

osim što je palpatorno ustanovljena manja rezistencija 

desnog jajovoda, vjerojatno zbog 

kroničnog upalnog procesa, koji je i uzrokovao 

ektopičnu trudnoću. Nažalost, nije urađena his-

terosalpingografija koja bi evaluirala konačni 

učinak terapije. 

U Bosni i Hercegovini cervikalne trudnoće, 

koje su inače rijetke, tretiraju se medikamentozno 

(12). Međutim, medikamentozno liječenje tubarne 

trudnoće, kao češće patološke pojave, nije 

uobičajeno. S obzirom da se radi o neagresivnoj, 

uspješnoj i jeftinoj terapiji, trebala bi se češće 

primjenjivati kod pravilno odabranih slučajeva. 

Literatura 

1. Grizelj V. Izvanmaternična trudnoća.U: Dražančić 

A i sur. Porodništvo. Zagreb: Školska knjiga, 

1994: 234-41. 

2. Čanić T, Ciglar S, Kašnar V. Combined intrauterine 

and tubal ectopic pregnancy. Ginecol Clin 

Oncol 1997;18: 92-3. 

3. Stowall TG, McCord ML. Early pregnancy loss 

and ectopic pregnancy. U: Berek JS. Gynecology. 

Baltimor: Williams and Wilkins, 1999:487-523. 

4. Lavie O, Beller U, Neuman M, Ben-Chentrit A, 

Gotteshalk S,Diamant Y. Maternal serum creatinine 

kinase: a possible predictor of tubal pregnancy. 

Am J Obstet Gynecol 1993; 169:1149–50. 

5. Ness R, Mclaughlin M, Heine R, Bass D, Mortimer 

L. Fetal fibronectin as a marker to discriminate 

between ectopic and intrauterine pregnancies. 


6. Kupešić S, Kurjak A. Uloga ultrazvuka u otkrivanju 

i liječenju ektopične trudnoće. U: Kurjak A. i 

sur. Ultrazvuk u ginekologiji i perinatologiji. Zagreb: 

Medicinska naklada, 2007:194-208. 

7. Jurković D, Jauniaux E, Kurjak A, Hustin J, Campbell 

S, Nicolaides KH, Transvaginal color Doppler 

assessment of uteroplacental circulation in 

early preganacy. Obstet Gynecol 1991;77:365-9. 

8. Shepard RW, Paton PE, Novy MJ, Burry KA. Serial 

beta hCG measurments in the early detection 

of ectopic pregnancy. Obstet Gynecol 1990, 

75:417. 

9. Čanić T, Fistonić I. Laporoskopsko liječenje 

ektopične trudnoće. Gynecol Perinatol 2008; 

17:73-6. 

10. Šimunić V. Izvanmaternična trudnoća.U: Šimunić 

V i sur. Ginekologija. Zagreb: Naklada Ljevak, 

2001:183-94. 

11. Bradamante V. Kemoterapijski lijekovi protiv 

zloćudnih tumora. U: Medicinska faramakologija. 

Zagreb: Medicinska naklada, 1999:471-488. 

12. Farquhar MC. Ectopic pregnacy. Lancet; 2005; 

366:583-91. 

13. Mol BW, Hajenius PJ, Engelsbel S, Ankum WM, 

Hemrika DJ, Van der Veen F, Bossuyt PM. Treatment 

of tubal pregnancy in The Netherlands: an 

economic comparison of systemic methotrexate 

administration and Laparoscopic salpingostomy. 


14. Sowter M, Farquhar C, Petrie K, Gudex G. A 

randomised trial comparing single dose systemic 

methotrexate and laparoscopic surgery for the 

treatment of unruptured tubal pregnancy. Br J 

Obstet Gynecol 2001; 108:192–203. 

15. Lipscomb GH, McCord ML, Stovall TG, Huff 

G, Portera SG, Ling FW. Predictors of success 

of methotrexate treatment in women with tubal 

ectopic pregnancies. N Engl J Med 1999; 

341:1974–78. 

16. Barnhart KT, Gosman G, Ashby R, Sammel 

M. The medical management of ectopic pregnancy: 

a meta-analysis comparing “single dose” 

and “multidose”regimens. Obstet Gynecol 2003; 

101:778–84. 

17. Perdu M, Camus E, Rozenberg P, Goffinet F, 

Chastang C, Philippe HJ, Nisand I. Treating ectopic 

pregnancy with the combination of mifepristone 

and methotrexate: a phase II nonrandomized 

study. Am J Obstet Gynaecol 1998; 179:640–43. 

Extrauterine pregnancy treated 

with Metrotrexat 

Ljiljana Bilobrk Josipović, Branka Lovrinović, 

Anton Galić 

Department of Obstetric and Gynecology, Croatian Hospital “Dr 

Fra Mato Nikolić “ Nova Bila, Bosnia i Herzegovina 

ABSTRACT 

Case report 

In this report we are describing a case of a patient 

whose tubal pregnancy was medicated with 

metrotrexat. The patient visited gynecologist 

10+1 week after the last period, complaining 

about mild pain in the lower abdomen area and 

scarce vaginal bleeding. After ultrasound and 

biochemical markers examinations the extrauterine 

(tubal) pregnancy in the right oviduct was 

diagnosed. The initial level of β hCG was 5005 

mIU/ml and the size of gestational sac was 51 

mm x 47 mm with an embryo 5 mm long. The 

patient was successfully cured with one 50 mg 

ampule of metrotrexat, intramuscularly applied. 

Key words: extrauterine pregnency, metrotrexat, 

values of β hCG-a 

Original submission: 19 March 2009; Revised submission: 20 

April 2009; Accepted: 06 May 2009.; 

283

284 

ERRATUM 

Quality of the cardiovascular drugs prescribing in Zagreb during 

the period 2001- 2004 

Danijela Štimac 1 , Josip Čulig 1 Ivan Vukušić 1 , Albert Cattunar 2 ,Dražen Stojanović 2 

1 Zagreb Institute of Public Health, Zagreb, Croatia, 2 Department of Epidemiology, School of Medicine, University of Rijeka 

Volume 6 Number 1, 2009., page 118: 2 Department of Health Ecology (instead Department of 

Epidemiology)

MEDICINSKI GLASNIK

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