antimicrobial treatment of complicated intraabdominal infections and the new IDSA guidelines.pdf

8/20/2019 antimicrobial treatment of complicated intraabdominal infections and the new IDSA guidelines.pdf

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J 28, 2011 115"" A A "&A ""A

Ab'&acFLDQ, F MHL G L &A MDFK GJ LLJLEFL G GEHDL FLJGEFD FLGFKK F HMDK. G MDF F LJ GJ DD NJ-LGFK F GDGQ, FLEJGD JKKLF HLLJFK, H-LFL JLJKLK F HJKFLLGF, DL J FJEMJKEFL KQKLEK F EFQ JFL GMFLJK. &FL KGJL LE L &A MDFK N F ND-D, FMEJ G HJLD DFD KKMK N F

JK Q HQKFK JJF FLJHJLLGF G LMDFK. EF LD KKMK G L FO &A MDFK J KJ K GDDGOK:

MLGJK G L &A MDFK HJKFL JGE-EFLGFK GJ L GDDGOF KMJGMHK G \GEHD-LW &A&: GEEMFLQ-IMJ FLJ-GEFD F-LGFK G ED-LG-EGJL F KNJLQ FDL J-KKGL FLJ-GEFD FLGFK (FGFJD LJLEFL JGEEFLGFK, GFDQ FGJELGFGML FLEJGD LJHQ G KH JKKLFL L-JD KGDLK). JGE DFD HGFL G NO, \GEHD-LW &A& J LLJ JFLL FLG HJEJQ, K-GFJQ (GEEMFLQ-IMJ F HGKLGHJLN) F

LJLJQ HJLGFLK. GK J L DFD HJKFLLGFKG &A& K KF F L EJFQ JGGE, L FJD OJ F GF &. MLMJ FLGL LJLEFL KLMKG &A& OGMD EGJ DFDDQ JDNFL LQ F-DM HLFLK F KLMK GJ L Q F KLQ G FLGLK GJ L LJLEFL G L GN EFLGFGJEK G &A&, JLJ LF GFMLF KLMK K GFL NM LJE \GEHDLW FLJ-GEFD F-LGFK.

FO &A MDFK GJ L LJLEFL G J-KKLFL LJ D LG EFLGF EFQ G FO NDDJMK, DLGM DFD L GJ L LJLEFL G \GEHDL &A&W OL FO KMKLFK PKL. MJLJ-EGJ, LJLEFL JGEEFLGFK GJ &A& MK Q

" J FGL FDM. K JGMH G KKK GE-HJKK FGM HLFLK (.. L FLJ JGMH G HGKLGH-JLN F LJLJQ HJLGFLK, JMJJFL FLJNFLGFK

F D ML KMJJQ GJ FJGLRF HFJLLK) LG HJG- N KH JGEEFLGFK GJ KM FLEJGDLJLEFL.

A HFD G "MJGHF GDDMK JGE KMJJQ, F-LFKN J, DFD EJGGDGQ F FLGMK K-KK K NDGH JGEEFLGFK K GF LGN EFLGF DFD FLLK OL L E G HJG- NF DJ LJHML JGEEFLGFK GJ KHDFD FGKK. AF FNMD HLFL-FLJ H-

HJG GJ LK NJQ EHGJLFL JGMH G KKK OL KMKLFLD EGJLQ F EGJLDLQ K KKFLD GJGHLED FLEJGD LJLEFL.

"A"

FLDQ, F MHL G L &A MDFK GJ LLJLEFL G GEHDL FLJGEFD FLGFKK F HMDK 1. K GEHJFKN GMEFLK F LGJGMDQ GDDL Q JCFGOF PHJLK FL D F LK FDMF PLFK ODD QGF LA, ECF L OGJDO GD KLFJ EEL-DQ LJ HMDLGF. GONJ, L K MDF, F FG

MDF F LJ GJ DD NJLGFK F GDGQ, FLE-JGD JKKLF HLLJFK, HLFL JLJKLK FHJKFLLGF, DL J F JEMJKEFL KQKLEKF EFQ JFL GMFLJK. &F L KGJL LE LMDFK N F MK DFDDQ, KNJD JK G GFMKGF N JKF F F FL. GDDGOF KM GKJNLGFK F HJKGFD PHJFK, HFD G "MJGHF GDDMK JGE KMJJQ, FLFKN J, DF-D EJGGDGQ F FLGMK KKK EL KNJDLEK LG KMKK L HJGDEL KKMK KKGL OLL FO &A MDFK.

GDDGOF JGEEFLGFK F GKJNLGFKGF NJQ EHGJLFL JGMH G KKK OL KMKLF-LD EGJLQ F EGJLDLQ J FGL EFL LG KLF F

GFLJL LG L &A MDFK, ML JLJ LG KGE FGJELGF F MF GJ L EFEFLG GEHDL FLJ-GEFD FLGFK OJ L

"MJ K (2011) 16: 115-126 T &. GDRHD MDKJK 2011

A&&b&A "A" \&A"W &A- Ab&A&"& A " " &A $&"&" V

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1HJLEFL G $FJD, KJD F GJ MJJQ, DFCME F, AE GKHLD G D FNJKLQ FFGNJ, $JEFQ 2GQD EHKJ GKHLD, FKLJ, FL FGE

3HJLEFL AFKLK FELGF, GHLD bL DM bJFJ, AKKKLF MDIM GHLMP JK F MFNJKL JK && FK JGL , J K, JF

4&FKLLML G AFLEJGD EGLJHQ, EGDFKC LL D AEQ, MKK5HJLEFL G MJJQ, LGD FNJKLQ, GDDFG A. $EDD, GE, &LDQ


2/12

MLGJK DN L GMD G NDM GJ DFFK LJL-F LGK HLFLK. EF GFLFLGMK KKMK F LJFL &A MDFK J K GDDGOK:

&" 1 V "&&&

&A FK GEHDL F MFGEHDL F-

LJ-GEFD FLGFK. &F GEHDL FLJ-GE-FD FLGFK L FLGF PLFK QGF L GD-DGO NKMK G GJF FLG L HJLGFD KH F KKKGL OL LJ KKK GJELGF GJ HJLGFLK, OJK F MFGEHDL FLGF FNGDNK FLJ-EMJD FDEELGF G L KLJGFLKLFD LJL 1.

K HHJK LG F JLD JFLLGF OGK FGL DOQK LJFKDL FLG DFD JDLQ. GJ F-KLF, HLFL OL F HHFLK OL LH G -JF GF LGH G L HHFP (KKME EGJLDLQ: 0.5-2%) K \GEHDLW &A& GJF LG LK F-LGFK OJK DGKLJME D-KKGL GDLK OL -JGLQH 027 (EF EGJLDLQ: 20-30%) K F

\MFGEHDLW &A& GDDGOF L &A JLJ. AGEHDL &A& K F KL Q LK GMJK F DF-D KNJLQ F FGL FKKJDQ Q LK DGD PLFL. JGJ, L GN EFLGF FLGF KGMD MK OL MLGF.

MLGJK G L &A MDFK HJKFL LJL-EFL JGEEFLGFK GJ L GDDGOF JDQ -F KMJGMHK G \GEHDLW &A&: GEEMFLQ-IMJ FLJ-GEFD FLGFK G ED-LG-EGJ-L F KNJLQ F DL J-KKGL FLJ-GEFD FLGFK. J J FG FJD EHJDLJLEFL JGEEFLGFK, GFDQ FGJELGF GF F-LEJGD LJHQ G KH JKKLFL LJ.

JGE DFD HGFL G NO, \GEHDLW &A&

J LLJ JFLL FLG HJEJQ, KGFJQ (GE-EMFLQ-IMJ F HGKLGHJLN) F LJLJQ HJ-LGFLK 2. GK J L DFD HJKFLLGFK G &A&K KF F L EJFQ JGGE, L FJD OJ FGF &. &F JFLDQ HMDK EFMKJHLK DF OL JLD GFLGFK F &A& L MLGJK N J-JJ LG L GN EFLGF FLGFK 3, 4. JGJ, L K EM DGKJ LG DFD GFLGFK MDFK GDDGO LK DKKLGF. HFD DNKLL MJLJ KLMK GF FLEJGD FLK F &A&KGMD FGL DGFJ JJ LG \GEHDLW F \MFGE-HDLW K LK DK LG EPLMJ G NJQ JFLDFD FLLK F LJGJ EQ OCF L NDM G

LK KLMK. &L OGMD EGJ MJL F MLMJ LGFDM HLFLK F KLMK GJ L Q F KLQ G FLGLK GJ L LJLEFL G GEEMFLQ--IMJ KGFJQ HJLGFLK, HGKLGHJLN KGFJQ HJLGFLK F LJLJQ HJLGFLK, JKHLNDQ, JLJLF LG GFML KLMK K GF L NM LJE\GEHDLW FLJ-GEFD FLGFK.

&" 2 V "&A b A"&A, A&b&&&"& A A&b&& "A&

M LG L KMKLFLDDQ FJKF, ML GJHDDQ NJQF HJNDF G JKKLFL $JE-HGKLN F$JE-FLN HLGFK LJ N F FMEJGMK

GJLK LG FGMJ JKJ F L NDGHEFL G FO FLEJGDK OL Q F KLQ F LK D5. AK JKMDL, FO FLGLK OL Q FKL J-

KKLFL LJ (DFRGD FKL A F ", H-LGEQF FKL A F ", LQDF FKLA, ", "b-HJGMF "FLJGLJ,JHFE-JKKLFL LJ) N KGOF LNLQ F NLJG F F NNG 6, 7, 8. FGJLMFLDQ, L FO &AMDFK GJ L LJLEFL G JKKLFL LJ KME-EJR F LD GML LJLEFL G \DL-J K-

KGL GEHDL FLJ-GEFD FLGFW D LGEFLGF FQ G LK JMK 1, DLGM DFD LGJ L LJLEFL G \GEHDL &A&W PKL GJ DF-RGD F LQDF O K HHJGN GJ \&A&W 8-10, 11*, 12* (*=HMDK LJ L &A MDFKN F HMDK). JLFDQ, L DFD L GJ DDG L EFLGF JMK F \&A&W J OC F GF-JFK GML F FJK EGJLDLQ JL MFJ LQ-DF LJLEFL JEF (GJ \&A&W L EGJLDLQ JL OK 0.7% (FGF-KFFLDQ) J F L LQDFJGMH LF F L GEHJLGJ JGMH) 8, 13. GONJ,JFGER GMD DF LJDK GJ L Q FKLQ G F FLGL F L LJLEFL G \&A&W

MK Q JKKLFL GJFKEK KM K A, " GJ"b-HJGMF "FLJGLJ J MFDCDQ LG JJ GML. GFKIMFLDQ, K DGF K EGJ LF GFLJHML DLJFLN K NDD, L HHDLGF G FLGL NJKLQ HHJK LG NJQ MKMD LGGD FGJJ LG JM L FLGL KDLN HJKKMJ GF FQ KMKLF K HJL G F FLGL KLOJKH HJG-JE 14-17. &L K FHHJGHJL LG JKLJL LJLEFLJGEEFLGFK GJ A F &A& LG NFGEQFF GJ "b-HJGMF "FLJGLJ LG J-HFEK F HHJDDF/LRGLE 1. A JGE-EFLGF LL FDMK L PKLF NJLQ G FL-GLK OL DFD L JGE L LJLEFL F &A& (NF-GEQF, DFRGD F LQDF GJ A, DFRGD

F LQDF GJ ", JHFEK, HHJDDF/LRGLE, LQDF F GDKLF GJ "b, K D 5) HJGNK G LOF KMKLFK F LJEKG F FNMD HHJG LG NJQ HLFL OL EF-ERLGF G LGPLQ F JKKLF NDGHEFL.

&" 3 V ", AbA""A"-&$ A$", AcinetobActer .

FO &A MDFK G FGL FDM FQ LJL-EFL JGEEFLGFK GJ &A& MK Q ". MLGJK G L MDF KJ GFDQ HLFLK KM KDNJ LJFKHDFL JHFLK OL F FLJ-GEFD F-

LGF GJFLF F L HLGDJQ LJL GJ HLFLKCFGOF LG GDGFR OL " K JKC LGJ. &FL, L NDM G L EFKLJLGF G F FL-FLJG-GD FL GJ L HJGFGKK G HLFLK OL &A& KKMKK GFLJGNJKD, ML L FLJ JGMH G HGKL-GHJLN F LJLJQ HJLGFLK, JMJJFL FLJNF-LGFK F D ML KMJJQ, FJGLRF HFJLLK, FLGK OL NDNMDJ JL KK GJ HJGKLL F-LJNKMDJ ELJDK N KMKLFLD JKC (NJQF JGE GMFLJQ LG GMFLJQ F JGE GKHLD LG GKH-LD) GJ FNGDNEFL G " O K JKC LGJ GJLJLEFL DMJ F L. K JGMH G KKKGEHJKK FGM HLFLK LG HJGN KH JGE-EFLGFK GJ KM FLEJGD LJLEFL. K

J KGOF F D 5, K ODD K JGEEFLGFK GJL LJLEFL G HFEK-HJGMF LJF A! '* # +a! # KHH.

""A A "&A ""A116 J 28, 2011


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&& A "A" &&"

&FLJ GEFD FLGFK (&A&) J GEEGF. -LGFD F FLJFLGFD LKK KGO LL GF FGMJ KK G KNJ KHKK GJ KHL KGC K MKQ &A&. &L K L KGF EGKL GEEGF GMK GKHL KGC LJ HMDEGFJQ MKK 18-20. ADEGKL

90% G DD FLJ GEFD FLGFK J KG DDKGFJQ HJLGFD FLGFK F JIMJ HJEJDQ KMJD HHJG (.. HHFLGEQ GJ HJGJL- HHFLK). J K GNJODEF NFGJ FLGL LJLEFL GEHJ LG HDG F LKKK JGMH 21. GONJ, HJEJQ FIMLF FHHJGHJL FLGL JEFK N KMKLF-LDDQ OGJK HJGFGKL GMLGE GJ HLFLK OL &A&F MK KMKLFLD FJK F DL J GKLK 22-24.

GEEFLGFK GJ L EHJD FLGL LJL-EFL G &A& J K GF EMDLLM G HJGKHLNJFGER F GFLJGDD KLMK. GEHDL &A&,

Q FLGF, J FGL FKKJDQ KNJ KK. &FLJDK KF GJ KGOF IMNDF G FLGLKGJ MK GJ JKLJLGF G FO FLGLK L YMKMDZFLJ-GEFD FLGFK FJGDD J KKGL OL

F AA" && KGJ LOF 4 F 6. AEF LGKGO LJHML IMNDF, NF L JKMDLK G JFL GJF FDQKK OJ FGL D LG EGFKLJLKMHJGJLQ G FQ HJLMDJ FLGL GJ LJLEFLKE 21.

&F LK EFMKJHL NJQ FLGL / JGMH G F-LGLK K HJGN OL KH DND G NF

F KLJFL G JGEEFLGF KGOF O KEG LJ 25, 26 F KGOF F D 1. DNDG NF GDDGOK L IMDLQ G KLMK GJ L KH- JM, L KLJFL G JGEEFLGF LCK GF-KJLGFK G LGPLQ F HGLFLD GJ NDGHEFLG JKKLF FLG GMFL.

GGKF L JL FLGLK GJ HJLMDJ H-LFL KGMD FDMF Q EMDLLM G LGJK,.. HLFLK (G-EGJLK, EEMFG-KMHHJKKGF, HJ- NGMK FLEJGD LJLEFL), PHL EJGDKHLJME, DGD LJD F JKKLF KLLKLK, KG HHDLGF, DND G LGPLQ F GKLK.

&F JFL QJK L NDMLGF G FLGL LJL-

EFL KEK OJ EHJGN LJGM JFLLF HJLGFLK KMJGMHK. K MDFK GDDGO LDFD FLGFK G HJEJQ, KGFJQ F LJLJQ HJLGFLK (DK 2-4), K GF 35. &FJKF

""A A "&A ""AJ 28, 2011 117

ta(# 1. NDK G NF F KLJFL G JGEEFLGF EG LJ 25, 26.

Le*e #f e*ide"ce E$a"ai#"

1 L-FDQKK G JFGER GFLJGDD LJDK, GG IMDLQ JFGER GFLJGDD LJDK GJ YDD

GJ FGFZ KLMK F O FG LJLEFL K FGL F GHLGF

2 YGO IMDLQZ JFGER GFLJGDD LJDK (


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FMEJK G &A& MK Q EMDL-JKKLFL FLK(A, ", "b-HJGMF "FLJGLJ)

GJ MDL LJLD KHK (.. P#"+)+*a , ca*"'- "a ) OJ GEEGL Q PLJ L (DK 5, 6).

""A A "&A ""A118 J 28, 2011

ta(# 3. GEEFLGFK GJ FLD LJHQ G JFL GJEK G KGFJQ HJLGFLK. b&=bL-DLEK FLGJ,A=LDDF JKKLFL . MJMK, "= FGEQF-JKKLFL "FLJGGMK KHH., "b= PLF KHLJME L-DL-EK HJGMF KHK, EL.=ELJGFRGD, + = GEFLGF OL FLGLK GNJF JE FLN F FJG KHKJIMJ, #= GEFLGF OL KMGEGFK-LN FLGLK JIMJ KMGEGFK K KMKHL; *=MK FLGL GFDQ DGD KMKHLDLQ JLK J U90%.

Diag"#'i' Like #&ga"i'! I"iia he&a$ Le*e #f e*ide"ce S&e"gh #f&ec#!!e"dai#"

C#!!"i-ac%i&ed "FLJGLJ HDGKHGJF JGMH 2 /3 1/1 A/A

#caied $e&i#"ii' "FLJGG + ELJGFRGD

(e.g. &ece" $e&f#&aed AFJGK AEFGHFDD F/b& 1 A

a$$e"dicii') AQDEFGHFDDF/b& 1 A

HJGDGPF* + L. 1 b

C#!!"i-ac%i&ed "FLJGLJ HDGKHGJF JGMH 3 + 1 A

diff'e $e&i#"ii' "FLJGG ELJGFRGD

+- &i'k fac#&' AFJGK AQDEFGHFDDF/b& 1 A

(e.g. $e&f#&aed c##"ic &EHFE-DKLLF 1 A

ca&ci"#!a) JGHFE 1 A

GJHFE 1 A

"JLHFE 1 AGPDGPF 1 A

QDF 1 b

HE 1 b

HJGDGPF*+ L. 1 b

NGDGPF* + L. 1 b

N#'#c#!ia "FLJGLJ &EHFE-DKLLF 1 A

$#'#$e&ai*e, $#'- "FLJGG JGHFE 1 A

&a!aic #& $#'- AFJGK GJHFE 1 A

i"e&*e"i#"a diff'e LHQDGG AQDEFGHFDDF/b& 1 A

$e&i#"ii' "JLHFE# 1 A

(e.g. a"a'#!#ic QDF# 2 A

eakage f##i"g GPDGPF 1 b

ie#&a"'*e&'#'#!) A

" K D 5

"b

F KHH. K D 6

ta(# 4. GEEFLGFK GJ L FLD LJHQ G LJLJQ HJLGFLK. #= GEFLGF LJHQ OL HKMGEGFK-LNFL JIMJ KMGEGFK K KMKHL


Pe&'i'i"g $e&i#"ii' "FLJGLJ &EHFE-DKLLF 2 A

de'$ie ade%ae ("FLJGG) JGHFE 2 A

'&gica a"d i"iia (LHQDGG) AQDEFGHFDDF/b& 2 A

a"i!icbia he&a$ AFJGK QDF# 2 A

"JLHFE# 4 b

LJPGF+ 4 b

LJGFRGD

A, "

"b K D 5

KMGEGFK KHH.

F KHH. K D 6


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J J FG JDD L QL JJF LJLEFLMJLGF G &A&. GDDGOF JGEEFLGFK JK GF LJHQ FLJNDK KLL F JFGEK KLM-K, FGKL JLJKLK G J LF FLGMKFLK (.. ca*"'"a KH.), OLJ L FLGF K DGD

GJ KQKLE, K ODD K L MLGJZK PHJF. F-NJ L HLFL K EHJGNF DFDDQ F FDEE-LGJQ KFK JKF, L FLGL KGFLFMLGF

KGMD GFKJ, KHDDQ LG HJNFL HLGFKDLGF F MFKJD K LK. K LJLEFLKMKK, NF F KNJ FLGFK, FGL GMJJ LJ 7QK, L LJLEFL KGFLFMLGF KGMD GFK-J F NGMJ G JHL MDLMJ KEHDF, KHDDQ

LG HJNFL KDLGF G EMDL-JKKLFL HLGFK FHGKKD LGP K LK. ALGFD EF HJG-MJK, KJ G GLJ G G FLGF, F G KM-

""A A "&A ""AJ 28, 2011 119

ta(# 5. DMDL F LJL FLGL LJHQ OL KMKHL GJ HJGNF &A& OL EMDL-JKKLFL FLK (A=LDDFJKKLFL . MJMK, "= FGEQF-JKKLFL "FLJGGMK KHH., "b= PLF KHLJME L-DLEK HJGMF KHK, + = GEFLGF OL FLGLK GNJF JE FLN F FJG KHK JIMJ, # = GEFLGF OLKMGEGFK-LN FLGLK JIMJ KMGEGFK K KMKHL; [ = FG EGFGLJHQ, * =MK FLGL GFDQ DGD KMK-HLDLQ JLK J U90%.

Age" A"ibi#ic Le*e #f e*ide"ce S&e"gh #f &ec#!!e"dai#"

MRSA QDF# 2 AFRGD+ 3 AHLGEQF+ 4

FGEQF+ 4 bGLJEGPRGD+ 4

VRE QDF# 2 AFRGD+ 3 A

ESBL-$dci"g &EHFE 3 A(E. c#i, Keb'iea '$$.) JGHFE 3 A

GJHFE 3 A"JLHFE# 3 A

QDF# 2 A AQDEFGHFDDF/b& 3 A

GKGEQF[ 4 bP'ed#!#"a' '$$. &EHFE 4 A

JGHFE 4 AGJHFE 4 A

AQDEFGHFDDF/b& 4 AHE 4 A

AEFGDQGK[ 4 bHJGDGPF* 4 ANGDGPF* 4 A

Aci"e#bace& '$$. GDKLF 2 A QDF# 4 A

Ca&ba$e"e!a'e- QDF# 4 A $dci"g '$ecie' GDKLF 4 b

(i.e. KPC )

ta(# 6. JLEFL KLJLQ OL KMKHL GJ HJGNF FNKN FLJ-GEFD EQGL FLGF OL F KHH.

Diag"#'i' I"iia he&a$ Le*e #f e*ide"ce S&e"gh #f &ec#!!e"dai#"

C##"iai#" ih Ca"dida '$$. FGF 3 A

S'$eced #& $*e" i"*a'i*e DMGFRGD 3 A

!c#'i': 'abe $aie" GJGFRGD 4 b

S'$eced #& $*e" i"*a'i*e "FGFF 4 A

!c#'i': i"'abe $aie" (AFMDMFF,

KHGMFF, MFF)& F KHH. K

DMGFRGD-KMKHLD,

LH-GOF LJHQ LG

DMGFRGD GJ 3 A

GJGFRGD 3 A


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KIMFL J-GHJLGFK J GLJ KKMK LG JKK FLK KLLF.

JLGFLK K L EGKL JIMFL GJE G &A& GFKL-LMLK NJQ GEHDP JLGF G L HJLGFME FLK KLGDGD KLJMLMJ LG LJD, NJD, MFD GJED KLEMD. J EF GJEK G HJLGFLK F JFLL GJF LG LK MKLN HLGF-

KK, LK KHLJME G HLGFK F GJF LG KMJ-D F FLEJGD LJHQ 2:

&A "&&&

JEJQ (KHGFLFGMK LJD) HJLGFLK (b) GF-KLLMLK GFDQ GML 1% G DD HJLGFLK KK 27. BMNFD GJE K LK GJF F ELGFGMK KHJFLGF, MKMDDQ KLJHLGG, HFMEGG GJ NJQ JJDQ Ha#)+&'( '*$(#*a# . &F MDLK F L EBGJ-LQ G KK (70%), b K KKGL OL KLK FDGGD-KKGL DNJ JJGKK GJ GLJ MKK G JM EEMF KQKLE (30%). &L K FGK OF

L KLK FMLJGHD GMFL PK 250/MD 28. &FEGKL KK, L GFKLLMLK EGFG FLGF LJGMLJFKDGLGF GJ ELGFGMK KHJF. &F KLMKHGJLJQF L DFD KLLF JDKLDDQ, GFDQ F GML35% G KK L MKLN FL K KGDL F LFKJ EGF e. !+ (' , K(#'#((a ., KLHQDGG, F-LJGG GJ KLJHLGG. FKMFL JL G -LJD LLGF K PHDF LJGM L L LL FL DFD KLLF GFDQ GML 50% G KK OL bKLK K JNKL GJ MDLMJD LKLF 28.

JEJQ HJLGFLK F LMJMDGKK K MKMDDQ MKQ ELGFGMK KHJF.

FGEK LJDK GJ b LJLEFLK J JJ.GKL G L KLMK J JLJGKHLN OGJCK LL

KGMD DKK K LJLEFL KMJNDDF LJDK. GDDGOF JGEEFLGFK LMK G FGL KMHHGJLJ NF DNDK (D 2). AFLGLK MK OJLJPGF, GLPE, LRE K ODD K Q-DEFGHFDDFK OL FL-L-DLEK LNLQ 28-31. L LK FLK DFD MJ JLK G MH LG 83% OJ N.

"&&& A&A" & A

A KKGL HJLGFLK K MKMDDQ MK Q LM-GJ LLJ GFLEFLGF. GKL JIMFLDQ FNGDNMKLN FLK J GMDK-FLN KLHQDGG

F Sa&(+!+!! a# . LJ DKK JIMFL F- NGDN FLK J e. !+ (' , FLJGG, GLJ KLJHLG-G, P#"+)+*a a#%'*+a , FJGK, e*# +a! # KHH., A! '* # +a! # KH., P+# KH. GJ ca*"'"a KHK32. FGEHDL KK F LJL KMKKMDDQ Q F FLEJGD FLK LG L DQKK DM.FDQ F JJ F KJGMK KK FLGLK N LG NF FGL GFDQ FLG L HJLGFME ML HJFLJD K ODD. &F HLFLK OL JFD DMJ HHDL JMKN LG EGFLGJ F GKK BMKL. JGE-EF EHJD LJHQ K MKMDDQ KLJL OL NF-GEQF HDMK FLEF GJ JGMH 2 HDGKHGJF OL GJ OLGML HJGDGPF 33. LJHQ KGMD LF GFLFM LJ LJGDGQ JKMDLK N F

GLF. &F KK OL HJGNF A-, "- F"FLJGG (FD. ") FLGFK, FLGLK F D 4 KGMD HHD. &F KK OL HJGNF EQ-

GL A-HJLGFLK, FLK F D 5 KGMD GFKJ. & L FLGF K FGL GFLJGDD OLF 7QK, L HJLGFD DQKK LLJ EMKL JEGNF LGFD FNKLLGFK HJGJE F KJ GJ JKGF G HJKKLFL FLGF.

"A "&&&

GFJQ HJLGFLK K MK Q KLJGFLKLFD($&) HJGJLGF F K OL 80-90% Q J L EGKLJIMFL &A&. J FLGF, KMJD FLJNFLGF(.. HHFLGEQ F HJGJL HHFLK) EMKLGDDGO. A HJEJQ KMJD FLJNFLGF OL FLNGEFD DGKMJ F DFD KMJNDDF K -GE L LJLEFL G G GJ EGKL HLFLK OLKGFJQ HJLGFLK 34. GFJQ HJLGFLK F MJLJ JFLL FLG GEEMFLQ IMJ(GML 70% G DD ) F HGKLGHJLN (GML 30%).

& A&" "A

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GDDGOF KLJG-MGFD HJGJLGFK LJDGMFLK J MKMDDQ DGO (105 ) FDEGKL DOQK EP JG/FJG LJD F-LGF 35.

GDK ML HJLGFD FLGFK (.. ML H-HFLK OL PKLF HJLGFD GFLEFLGF G DKK LF 6 GMJK) KGO MKMDDQ DJ GJ DGMQ PM-L. KMDDQ NDD FLGLK J EFGHF-DDF/b&, QDEFGHFDDF/b&, JLHFE, DLJ-FLNDQ JGMH 2 HDGKHGJFK F GEFLGF OLELJGFRGD GJ LJPGF. JHQ MJLGF F

JM LG 1-2 QK F DGDR KK OL KGJL (


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A GJF FDQKK GJ bL DLE FLGLEGFGLJHQ NJKMK DLE-EFGDQGK FLGLGEFLGF LJHQ GJ KHKK FGL KGO FQ -LGFD HGKLN LK GJ EFGDQGK GEFLGFLJHQ 38. AEFGDQGKK KLDD N LJ HD FGEFLGF OL JG KHLJME KFKLN bL-D-LE-FLGJK (KHDDQ JHFEK, AQ-

DEFGHFDDF/b&) GJ L LJLEFL G P#"+- )+*a KHH. 39, 40. JD CFL HJELJK K ODDK GLG- F FHJGLGPLQ JIMJ JHL KJME-DN-D GFLJGDK.

"A&" "&&&

GKLGHJLN HJLGFLK K FGKGGED KGFJQ HJLGFLK GJE F F K F FLGMK GE-FD GEHDLGF GDDGOF KMJD FLJNFLGFK (..FKLGEGL FKMFQ GDDGOF FLJGJ JLMEJKLGF) 2. GKLGHJLN FLGFK GEHJ LGLJLJQ HJLGFD FLGFK DOQK JIMJ KMJD

HHJG 36, 37, 41. bMK G FGKL F LJ-HML MDLK K ODD K OGJK HJGFGKL LGJK,L K LK GOF FLLQ EGF KGFJQ HJLGFD F-LGFK 4. EBGJLQ G HLFLK J MKMDDQ DJQ GNJ Q FLGLK OF L FGKK K E FL EJGD MKK G KM HJLGFLK LF LG EMDLHD JM-JKKLFL () FDMF FLJGG(FD. "), $JE-FLN GJFKEK ("b GJ AEH GJ JHFEK-HJGMJ), A F ca*- "'"a KHK.

MK L G G FLGLK F LK KK FKLG FDMF Q DGD HEGDGQ F KMKHL-DLQ G KGDLK. AHHJGHJL FLK EQ JHF-EK, LQDF, HHJDDF/LRGLE GJ EGP-

DGPF HFF GF EJGD FFK (D 3) AFLMFD LJLEFL K JGEEF GJ HJGNF MF-D FLGFK (D 6).

"&A "&&&

JLJQ HJLGFLK K HJKKLFL FLJ-GEFD F-LGF OLGML KMJDDQ LJLD GMK, GDDGOF F JDJ KMJD FLJNFLGF F KGMJ GFLJGD 2.&F EGKL KK L FLGF K EFLF MK G KLL G EEMFGFQ F GJ M LG JKKLFL -LJ KDLGF GDDGOF FLGL LJLEFLK. LFLK OG EL NDGH LJLJQ HJLGFLK J NJQ -

MDL LG FLQ. GEHJ LG KK G KGFJQ HJ-LGFLK LJ J KFFL J &-KGJ, A&&-KGJ F DNL -KJME DNDK 41. KGJE G FGKGGED HJLGFLK KGOK KEDJ KLLJD KHLJME O K DKG GMF F HGKLGHJ-LN KGFJQ HJLGFLK. JIMFLDQ GMF LJFDM FLJGG (FD. "), KLHQDGG FD.A, FLJGLJ, FJGK F ca*"'"a KHK 36. GEHJ LG HGKLGHJLN HJLGFLK,L LJLJQ GJE GK FGL JIMJ FQ KMJD FLJ- NFLGF 2, 4 ML LK HGFL K MDL LG KKKK MFLD FGF-GFLJMLGJQ KMJD FLJNFLGF HJGNK LL LHLFL K F LJLJQ HJLGFLK. AFLGLKLL EQ OGJC F LK KMJGMH G HLFLK J LJ

JGMH 1 GJ 2 JHFEK, LQDF (F GEFLGF OL P#"+)+*a -LN FL JDNFL HLG-FL JGD G P#"+)+*a KHH. K KMKHL GJ

HJGNF), QDEFGHFDDF OL bL-DLE-FLGJGJ JGMH 3 HDGKHGJFK F GEFLGF OLELJGFRGD (K D 4) 36, 42. JLEFL J-GEEFLGFK GJ FNKN MFD FLJ-GEFD F-LGFK J GMF F D 6. GKL-HJLGFLK KKKGJELGFK KGMD JF -M F LJLGJF LG LK FLEJGD KHLJME.

&& "A A &-"&Ab A"&A

MJF L E FFLK 95-97% G DD &A& KKGLEJGK OJ KFKLN FKL GEEGFDQ MK FL-GLK ($JGMH 2 HDGKHGJFK OL ELJGFRGD,HJGDGPF) 43, F JFL QJK L KJ G JKK-LFL KHK N FJK OGJDO 41, 44, 45. "K-HDDQ F HGKLGHJLN F LJLJQ HJLGFLK K ODDK OL FLGLK HJLJL FJGLKF HFJLLK,GF K LG KKME F FNGDNEFL G JKKLFL GJ -MDL LJLD LJ (A, ", "b-HJGMJ,

P#"+)+*a KHH. A! '* # +a! # KHH. F JHF-EK-HJGMF GJFKEK) 12, 44, 45. &FNMDJKC-GFKLDDLGFK F DKG PKL, HJGJ LG L FLJ-GEFD FLGF, FLGL LJLEFLK GMJJ(.. FL L GGL). &F D 5 LJ K -KJHLGF G JFL KHK F LJLEFL JGE-EFLGFK (D 5).

A

&FLJ-GEFD FLGFK OL A F EEMFG-GEHLFL HLFLK J NJQ JJ. &F EGKL KKA-GDGFKLGF GDDGOK LJ DNF L GEFGHF (.. FLJ-GEFD GEHJLEFL KQFJGE).

GF-GEHJGEK HLFLK KGMD JN FLGLLJLEFL, LQ KGO DGD GJ KQKLE FDEELGJQ KFK GJ N HJKKLFL KGDLGF GMFL. ADDHGKL-LJFKHDFLLGF HLFLK OL LJGF FMEEMFGFQ F NF GJ A (GDGFR-LGF GJ FLGF) KGMD LJL. QDF GJKEGF L FO FL-A KFKLN FLGLK D-FK GJ &A& 8 F DKG GNJK L PHL $JE-FLN F FJG KHLJME. FL DFD LGJ L LJLEFL G -MK GEHDL &A& OL LQDF KGO DFD KMKK JLK LOF75-80% 10-12. & P#"+)+*a KHH. J GMF GJ KMK-HL LG JDNFL F MKF L FLGF,

P#"+)+*a -LN FL K LG . FRGDF HLGEQF J KGDDQ LN FKL $JE-HGK-LN LJ 6, 7, 9. GEHJ LG NFGEQF, LQ GJ GG LKKM HFLJLGF. DFD L GJ LLJLEFL G &A& OL DFRGD J NDD 9. F-RGD, HLGEQF F NFGEQF KGMD GE-F OL FLGLK GNJF $JE-FLN KHK,K FLJ-GEFD $JE-HGKLN EGFG-FLGFK JJJ 36. L GML GEEMFLQ IMJ A-&A&J MJJFLDQ FGL NDD.

""& &&$ "

"FLJGG J F FJKF MK G FGKGGED F-

LGFK. JGD G FLJGG K L HJEJQ HLGF F EMDL-LJD &A& K KMKK GFLJGNJ-KDDQ, KHDDQ K GQ G NF K KGOF KM-

""A A "&A ""AJ 28, 2011 121


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KKMD KMJD LJLEFLK G &A& OL FLLJDLJLEFLK OLGML FLJGGD GNJ 36, 37, 46."FLJGG-GNJF FLGLK J JGEEF FHLFLK OL HGKL-GHJLN HJLGFLK, LJLJQ HJ-LGFLK, KNJ KHKK G GEFD GJF F FLGL- HJLJLEFL GJ FGJLK-HJGF HLFLK (J-LGFLK F JL NDN JHDEFL) 37. &F DD LK

FLGFK OL HJNGMK FLGL LJLEFL, NF-GEQF-JKKLFL FLJGG J DCDQ LG FGMF-LJ OL ". ME NF JLJ HLGF HJGH-JLK LF ". DK. L L PHLGF G NF-GEQF, DD HJNGMKDQ EFLGF FLGLK J -LN FKL A. J DFRGD-JKKLFL FLJG-GD KLJFK N F KJ 47.

"b-&$ A$"

FL QJK N KGOF LJF EGF "FLJGL-J KHK (KHDDQ e. !+ (' , . HFMEGF) LG- OJK NDGHF JG L-DLEK-JKKLF F-

DMF JGMH 3 F 4 HDGKHGJFK, O J Q-JGDQK Q KG DD PLF-KHLJME L-DL-EKK ("b). A KHD JGD GJ L LJFKEKKGF G "b-KHK KEK LG L GDGFKLGF G L F-ED- F MEF $& LJL 48. J K JDLNDQ HJNDF G "b-HJGMF KHK F NKJDKMJD HJLEFLK 49. &F "b-FLGFK J-HFEK F LQDF J DEGKL L GFDQ FLK G G. &FLGFK OL KLJFK JKKLFL LG JHF-EK, DMGJGIMFGDGFK F LGJEQF F GFDQ LJL OL LJ LQDF GJ GDKLF 39, 40. J K F MJFQ GJ L NDGHEFL G LNFO FL-$JE-FLN FLK.

P SeudomonAS ., AcinetobActer ., AbA""A"-&$ b A"&A

P#"+)+*a KHK J LL F GML 8% G DD&A&, OJK L HJFL G MKLN KLJFK KDCDQ LG EM DGOJ 50, 51. bKDDQ JGMH 3HDGKHGJFK, JGMH 2-4 DMGJGIMFGDGFK, J-HFEK, HHJDDF/LRGLE F EFGDQG-KK J NDD, OL GEFLGFK G GN JGE-EF 52. &F L NFL LL 4 GJ EGJ MKMDDQ ND-D #"+)+*a -LN FLK LMJF GML LG F-LN (KG DD HF JM JKKLF ()), GDKLF KNDD GJ LJLEFL DLGM L L JJF L

LJLEFL G P#"+)+*a FLGFK J KGF FGKGGED HFMEGF F KHKK ML FGL PHDL-DQ GJ HJLGFLK 39, 40. KE GK GJ JHF-EK-HJGMF HLGFK F AFLGLJKHK, OJ LQDF F GDKLF J L GFDQ LJLEFL GHLGFK.

"KHDDQ F FLGFK MK Q EMDL-JKKLFLLJ, L K G HJEGMFL EHGJLF LG FLHLL KHLJME G LJ OF FLLF FLEJGDLJHQ. & LJD FLLGF L F KMKHLD-LQ HLLJFK J FGL KGOF FQ JKKLFL HLGFK,-KDLGF KGMD HJGJE.

&A- Ab&A $A &"&

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"a -LLGF F FLGFK GF &'K N FJK FL DKL 20 QJK. AGML 18% G DD KNJ KHL F-LGFK EQ MK Q ca*"'"a KHK F G LGKKK 25% J FNKN FLJ-GEFD EQGKK (&&)20. FF ca*"'"a KHK F KOK GLF FLJ-GHJLNDQ KEK LG GJJDL OL J DLDLQ 53. L LL FGKF && LJGM EFK GL-

J LF DGG MDLMJK K NJQ MDL EL PHDF EM J HJNDF. JGG G && K NF GJca*"'"a KHH. JGE FLJ-GHJLNDQ JNKL LKKMF, OL MLGF, L EJGKGH F MDLMJD L-LGF F KHJL KLK 54. FKLNLQ F KHLQ G KJGDGD LKLF ELGK N EHJGN, ML FFGL JD GF L HJKFL 55. LLF ca*"'"a KHK F LJD KJLGFK, MJF MDLMJ GJ OGMFKJLGFK J MKMDDQ MFGEHDL GDGFKLGFK FGL OJJFLF FQ LJLEFL. KE K LJM GJ F F-LJ-GHJLNDQ JNKL HGKLN KHEFK OLGEEMFLQ IMJ HJLGFLK (.. HJGJL KLGE- MDJ). & L HLFL K EEMFG-GEHLFL F

KLD, LJ K FG JIMJEFL GJ FLMFD LJHQ.JGFGKK G && K EM OGJK OL DQ LJL-EFL 54, 55. -JKC GDDLNK JGE KMJDHGFL G NO FDM HLFLK OL KNJ HGKLGHJ-LN HJLGFLK (.. FKLGEGL DC GDDGOF KGHGBBMFGKLGEQ), EKK HJGJLGFK (.. bGJ-N-KQFJGE) F HLFLK OL GEFD KHKK OL EMDLHD LKKM ca*"'"a -FKLLGF (.. HGKLNMJF MDLMJ F OGMF KJLGF) 54-56. &F LOGKLMK HJ-EHLN LJLEFL OL DMGFRGD KF-FLDQ JM FNKN MFD FLGFK ML D LGJM GNJDD EGJLDLQ GEHJ LG HDG 57, 58.NJLDKK, L NDM G HJEHLN FLMFD LJL-EFL K KMKK GFLJGNJKD 53-55.

F && K KMKHL GJ HJGNF, JFL FLMF-DK F GKF JGE (K D 6). A -GK-LJHQ OL DMGFRGD K KMFL GJ DMGFRGD-KMKHLD KLJFK, ML JKKLF G ca*"'"a KHH.FKL DMGFRGD K FJKF 59. &AMDFK GJ L LJLEFL G FNKN FKKJGEEF, LL HLFLK, OG J LJ FKLD GJN JFLDQ F NF F RGD LJHQ GJ HJGHQ-DPK, KGMD FLDDQ JN F "FGFF (FMD-MFF, KHGMFF, EMFF) 60. & L KGDLca*"'"a KHH. K DMGFRGD-KMKHLD, KLH-GOFLJHQ LG DMGFRGD KGMD HJGJE.

bMK G LK LGPLQ, EHGLJF b K GFDQ J-

GEEF K HJEJQ LJHQ F KK G HJGNF D-DJ JLGFK LGOJ GLJ FLMFDK 60. MJJFL-DQ 14 Q LJLEFL HJG K JJ K KMFL,K DGF K L DFD F ELGDGD JKMDLK JEHJGNF 60. FDDQ L KGMD FGL, LL F F- NKN FLJ-GEFD MFD FLGF F LJ DKK K G LJLJQ HJLGFLK, GJ KGFJQ HJ-LGFLK OL FKMFL KMJD KGMJ GFLJGD 59. &FL DKL K KMJD FLJNFLGF OL KMKKMDKGMJ GFLJGD K L HJJIMKL GJ KMKKMD FL-MFD LJLEFL.

"&&$ A"A&& & &"""&

KNJLQ G ML HFJLLK K EKMJ Q LHJKF GJ KF G KLFL GJF DMJ, DGD

""A A "&A ""A122 J 28, 2011


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GEHDLGFK GJ GL 61. MK L OGMD EHGJLFLLG FLQ HLFLK OG J PHL LG NDGHKJGMKGEHDLGFK, K LK OGMD JIMJ FLFKN EGFLG-JF K ODD K HGKKD KMJD FLJNFLGF. FJLFJGKK GFKLLML DFDDQ JDNFL GEHDLGF, O F NDGH OLF L JKL O QK G DDFKK.FGKK K MKMDDQ GF LJGM KFFF. JG-

KK K KKGL OL DL GEHDLGFK (GJJGKN -EGJJK, GJF HJGJLGFK) F FJK DLDLQ OF LQ GE FL. AGML 80% G DD HFJ-LLK KKGL LK J MK Q KHL GEHD-LGFK. LJFKDGLGF G GDGF LJ FLG LHJHFJL LKKM K L EGKL JIMFL MK G KM-HJFL HFJL FJGKK. &FL HFJLFJGKK F KMKHL, (MKMDDQ JGE OC LOGG DDFKK) HLFLK NDGH NJ, DMCGQLGKK, DNL-KJME DNDK F F ML MFPHL DFD -LJGJLGF. NKMDKLGF G J MDK OLFFJGL LKKM GF KFK K DQ KMKLN G F-LGF. &F LK F MFJLF KK, F MDLJKGMF- GJ

-M F FD KHJLGF KGMD GLFF KFL GJ DGJLGJQ LKLF ($JE-KLFF, EJG-GDGQ), O GMD FDMF LJHML KLJLQ FHLFLK DJQ LJL OL FLGLK 62.

LJLEFLK NDD GJ FL HFJLFJGKK J LJ GFKJNLN EKMJK (FGKGH-DDQ M LJFKKLJD JF, -M JF)GJ KMJD EKMJK. A KMJD FLJNFLGF (GHF GJ

EFEDDQ FNKN) K MKMDDQ KL HJGJE LJ 2 OCK FLG L KK HJGKK, K JDJ KMJD FLJ- NFLGFK JJQ J EGJLDLQ JKCK 63.

FLD JFLDQ, HJGHQDL EFKLJLGF G F-LGLK F FJGLKF HFJLLK OK JGEEF64. O KFL L N KGOF, LL HJGHQDLFLGL LJLEFLK N FG HGKLN FDMF GF L

GMJK G DDFKK 65, 66. &L K MJJFLDQ FGL JGE-EF LG FLL FLGL LJLEFL F FJGLRF HFJLLK OLGML FLGF 65-67. A DJ F-LGF GJ FLLJD LJLEFL K F DD KK OLHJGNF FL FJGKK, FL HKMG QKLK, -KKK GJELGF, GDFLK F GLJ PLJ-HFJLFLGFK. EGKL EHGJLFL LJ FNGDN F F-L HFJL FJGKK J "FLJGLJ, "F-LJGG, LHQDGG, AFJGK F ca*"'"a KHK. F GGKF L HHJGHJL FLGL, L KEHGJLFL FGL GFDQ LG LFC GML L KHLJME MLDKG GML IML HFJL LKKM HFLJLGF.LMK OL JDD L GJ IML LKKM HFLJ-

LGF PKL GJ IMFGDGFK (HJGDGPF, EGPDGPF),JHFEK (EHFE/DKLLF, EJGHFE, J-LHFE, GJHFE), ELJGFRGD, HDGKHGJFK(GLPE, LRE, HE) F HFDDFK (E-RDGDDF, HHJDDF/LRGLE). &FKMFL LKKMHFLJLGF K KGOF GJ EFGDQGKK 24. GKK-D FLGL LJHQ JEK J GMF F D 7. &FKMKHL GJ HJGNF FLGFK OL JKKLFL KHK

""A A "&A ""AJ 28, 2011 123

ta(# 7. DMDL FLGL LJHQ OL FJGLKF HFJLLK F KGFJQ GDFLK. (b&= bL-DLEK FLGJK,EL.=LJGFRGD, A=LDDF JKKLFL . MJMK, "= FGEQF-JKKLFL "FLJGGMK KHH., "b= PLFKHLJME L-DLEK HJGMF KHK, #= GEFLGF OL KMGEGFK-LN FLGLK JIMJ KMGEGFK KKMKHL; *=MK FLGL GFDQ DGD KMKHLDLQ JLK J U90%.


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(.. A, ", "b), JGEEFLGFK GJ JKK-LFL LJ J KGOF F D 5, GJ MFD F-LGFK F D 6.

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Q DJQ GKLJMLGF. MKK J MKMDDQ DDKLGFK,FF KLJMLMJK F JJDQ LMEGJGMK GKLJMLGFK(MKMDDQ KLJD). L L FJK G GKLJMLGF, LHJGDLQ G GDFLK JKK OL L HGKKDLQ G KQKLE LJE. A HGKLN D ML MDLMJ KGMF F GML 75 LG 100% F DJQ GKLJMLGF. LJD KHLJME FDMK "FLJGLJ, "FL-JGG F AFJGK. &F HGKLGHJLN LJE,GDFGF KHKK, KMHL KKKK F FLJ- NFLGFD HHJGK (" GJ FGKGH HHDDGLG-EQ), GLJ $JE-FLN DD F P#"+)+*a JFGMFLJ.

JEJQ LJHQ GJ GDGGDLKK K DJF

L DJQ KQKLE N " OL GFKMLN DHJG-KGH GDQKLLGEQ (KG DD LJHML KHDL-LF). KLJMLN GDFLK KGFJQ LG DDKLGFK,KGMD NF F KHL GFLGFK LJL Q FG-KGH JEGND G KLGFK. &FGHJD LMEGMJK F DKG KMKKMDDQ LJL OL KLFL-EHDFLK. A DMDL- FLGL LJHQ F KLJL OL LJ AEFGHFDDF/b&, AQDEFGHFDDF/b& GJ JGMH 3 GJ 4 HDGKHGJF F GEFLGF OLLJGFRGD. ADLJFLNDQ JGMH 1 GJ 2 JHF-EK GJ JGMH 2 GJ 3 DMGJGIMFGDGFK J EFKLJL- (D 7). & P#"+)+*a KHH. K FNGDN GJ KMK-HL, JDNFL P#"+)+*a -KFKLN KMKLFKGMD 35.

&&-&&&" A&A" &&

LJGFRGD F NFGEQF J L FLK G G GJ L LJLEFL G DGKLJME D F-LGF (&). &FLD MJ JLK G >90% N F J-HGJL. MDEFFL GJ GEHDL KNJ & F J-MJJFL & J ELLJK G GFJF. GEEF-LGFK GJ L LJLEFL G DGKLJME D F-LGFK N JFLDQ F HMDK Q 69.

ta*a#*! "#!(aa'+*: " K JN KHCJ GFGJJJGE RJ, QL, bQJ, F GNJLK F K HJL-HL GF NKGJQ GJK GJ QL F RJ. K J-

N KHCJ GFGJJ F KJN GF NKGJQ GJK GJRJ, QL, bQJ, FKKF-D, GNJLK. K J-N KHCJ GFGJJ F K HJLHL GF NKGJQ GJK GJ AKLJ F, FKKF D, F RJ. DJK FG GFDL G FLJKL. $ K JNJ KHCJGFGJJ F K HJLHL GF NKGJQ GJK GJ RJ.

""""

1. GDGECF , RMKC ", bJDQ L D. FGKK FEFEFL G GEHDL FLJ-GEFD FLGFK FMDLK F DJF: MDFK Q L MJD &FLGFGLQ F L &FLGMK KKK GLQ G AEJ.DF &F K 2010;50:133-64

2. DL A. "EHJ LJLEFL GHLGFK F L EF-EFL G GEHDL FLJ-GEFD FLGFK. DNDF 2007;74(KMHHD 4):29-37

3. AMMKLF , JEJJ , MDDJ-JQK , GFLJNJK

. KC LGJK GJ EMDL-JM JKKLFL LJ F GHL-ERLGF G EHJD FLGL LJHQ F HGKLGHJLNHJLGFLK. JL J 2010;14:20

4. bJ , JGJ , MBL , MD ", bJM ,"CEFF . MK HJGKLGHJLN HJLGFLK:NDM G FGKL HJELJK F EHL G JDQ FLGF GJJDHJGLGEQ. "MJ K 2009;14:1-6

5. bGMJ , DGL $, bJDQ L D. b MK, FGJMK: FG "A"! AF MHL JGE L &FLGMK K-KK GLQ G AEJ. DF &F K 2009;48:1-12

6. &LF , JQF , bLLJQQ , MFCD LD. "Q F KLQ G DFRGD NJKMK NFGEQF GJL LJLEFL G GEHDL KCF F KGL-LKKM F-LGFK HJGNF LG MK Q ELDDF-JKKLFL LHQ-DGGMK MJMK. AE MJ 2010;

7. AJL , C L D. KLQ F Q G H-LGEQF GJ L LJLEFL G GEHDL KCF F KCF-KLJMLMJ FLGFK. DF &F K 2004; 38: 1673-1681

8. bFC , "DDK-$JGKK ", JLGK L D. Q F KLQ G LQDF GJ L LJLEFL G GEHDLFLJ-GEFD FLGFK. DF & K 2005;41:354-67

9. bJEFE , QFJ , J A L D. FRGD- F L LJLEFL G EMDLJM-JKKLFL, $JE-HGKLNFLGFK: PHJF JGE GEHKKGFL-MK HJG-JE. DF &F K 2003;36:159-68

10. OGG , J , FJ L D. QDF GJ LLJLEFL G HLFLK OL KNJ KHKK GJ KHL KGC: JM NDMLGF F KMJD FLFKN J MFL. AFLE-JG EGLJ 2008;61:729-33

11. bKKLL , GDF , HLLG ", ", D bGFG , KGD . QDF MK F KJGMK FGKGGED F-LGFK: JM MK NDMLGF. b &FL K 2010;10:287

12. "CEFF , REFF , NGF " , LFJ ",SKEFF A, bGEFF . JGKHLN, FGF-FLJ-

NFLGFD EMDLFLJ LJD G LQDF F L LJLEFLG KNJDQ DD HLFLK. EGLJ 2010;19:165-166

13. LLH://OOO..GN/JMK/JMLQ/ME224370.LE

(DKL NKL F 15L 2011)14. JQF . GEHDL KCF F KGL LKKM FLGF. AFLEJG EGLJ. 2010;65 (3):35-44

15. DGP . L G FLEJGD JKKLF F K-DLGF. &FL AFLEJG AFLK 2009; 34 3: 6-10.

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18. MEJ A, GJLK , GG " L D. MJLGF G Q-HGLFKGF GJ FLLGF G LN FLEJGD LJ-HQ K L JLD LJEFFL G KMJNND F MEF KHL

KGC. JL J 2006; 34: 1589-159619. MEJ A, "DDK , AJ L D. &FLLGF G FHHJGHJ-L FLEJGD LJHQ JKMDLK F NGD JMLGF G KMJNND F MEF KHL KGC. KL 2009;136:1237-48

20. "FD , bJMFCGJKL , bGF $ L D. "HEGDGQ G KHKK F $JEFQ: JKMDLK JGE FLGFD HJGKHLNEMDLFLJ KLMQ. &FLFKN J 2007; 33: 606-618

21. GF , $DDE A, MEJ L D. AFLGL J-EFK GJ KGFJQ HJLGFLK G KLJGFLKLFD GJFF MDLK. GJF LK QKL N 2005; 18:004539

22. "DKJ , bJJ A, DD L D. "GFGE GFK-IMFK G DMJ G FLD FLGL LJHQ F GKHLD-R MDLK OL GEHDL FLJ-GEFD FLGFK.MJ &FL 2008; 9: 335-347

23. bJ . GKL G DMJ. MJ &FL 2008; 9: 313-31524. NQ $, JOC . AHHJGHJL NJKMK FHHJGHJLFLEJGD LJHQ. DF JGGD &FL 2008; 143:15-21

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25. PGJ FLJ G "NF-K F: DNDK G N-F (EJ 2009)LLH://OOO.E.FL/FP.KHP?G=1025 (DKL NKL: F15L 2011)

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28. EGD A, $J-KG $, NK L D. FGKK,LJLEFL F HJGHQDPK G KHGFLFGMK LJD HJ-LGFLK: GFKFKMK GMEFL. HLGD 2000; 32: 142-153

29. N $, F bA, F bA L D. GJL GMJK LJP-GF LJHQ F KHGFLFGMK LJD HJLGFLK. GKLJ 1998; 74: 592-599

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J 2001; 15: 1851-185931. GJL , NK , AJJGQG L D. "L G FLJNFGMK

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34. F MDJ , DJ , bGJ L D. GEHJKGF G GF-EF NK HDFF JDHJGLGEQ KLJLQ F HLFLK

OL KNJ HJLGFLK: JFGER LJD. AA 2007;298:865-872

35. bGEFF , $JF b L D. GEEFLGFK G L

MD-"JD-KGLQ GJ EGLJHQ GJ L EHJDFLEJGD LJLEFL G KNJ FLGFK G MDLK."CEFF , &KFEFF , MBL L D.: &FLJ-GE-FD FLGFK. EGLJ 2010;19:217-222

36. MHGFL . EHJ LJLEFL G FGKGGED FLJ-GEFD FLGFK. &FL &FL K 2007; 11(1): 1-6

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L . AFLJG EGLJ 2008; 62: 5-3440. $KC $, GFFL , JK L D. DFD F G-FGE EHL G GEEGF EMDLJM-JKKLFL $JE-F-LN DD. AFLEJG AFLK EGLJ 2008; 52:813-821

41. JGEC A, KJ A, SDDF L D. &FLLGF G HLFLK L JKC GJ NDGHEFL G LJLJQ HJLGFLK GF KMJD FLFKN J MFL. $KLJGFLKL MJ 2009; 13:1358-1367

42. RMKC ". AFLEJGD LJLEFL GJ FLJGEFDFLGFK. "PHJL HF JEGLJ 2007; 8: 2933-2945

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47. DD ", J , GKKM L D. FRGD-JKKLFL"FLJGGMK ME F "FLJGGMK DK KGDLJGE KHL HLFL: JHGJL G JKL KGDLK F $JEFQ.&FLGF 2004; 32: 182-183

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GDGFRLGF. JL J 2006; 34: 730-73757. DR , FJP , OGG L D. GMD-DFHDG-GFLJGDD LJD G DMGFRGD LG HJNFL F-D FLGFK F JLDDQ DD KMJD HLFLK. AFF MJ 2001; 233: 542-548

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61. LGE . AML HFJLLK. "F 2006;354: 2142-215062. bFCK A, $JRGN $, FNF " L D. -M K-

HJLGF G KMKHL HFJL FLGF: LJGDGQ F DFD GMLGE. &FL FJLGD 1995; 18: 265-270

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