ᲨډᑣჄᇌʞఱ၏ᨈư౨ЈƞǕƨ ᵣᵱᵠᵪ ငဃٻᐂᓏƴ᧙ƢǔǵȸșǤȩȳǹ ۑኳ㔝㞞அ㸦ᪧᡤᒓ ዉⰋ┴❧ᲄ㝔 ⌧ᡤᒓ ༡ᗈᇦ་⒪ᴗᅋ ༡ዉⰋ⥲ྜ་⒪ࢭࣥ ࢱ࣮㸧 㡭ᶫಙ㸦ᪧᡤᒓ ዉⰋ┴❧ᲄ㝔⣽⳦᳨ᰝᐊ ⌧ᡤᒓ ዉⰋ┴❧་⛉Ꮫ㝃ᒓ㝔⮫ ᗋ᳨ᰝ㒊㸧 ࠙◊✲┠ⓗࠚ ㏆ᖺࠊඛ㐍ㅖᅜ࠾ࡅࡿ⭠ෆ⣽⳦⛉⣽⳦ࡢ⸆⪏ᛶࡀୡ⏺ⓗၥ㢟࡞ࡗ࡚࠸ࡿࠋ௨๓ ࡣ㝔ෆឤᰁࡢཎᅉ⳦ࡋ࡚ၥ㢟どࡉࢀ࡚࠸ࡓࡀࠊࡣᕷ୰࡛ࡢឤᰁࡸタෆ࡛ࡢಖ ⳦⪅ࡢቑຍࡶሗ࿌ࡉࢀ࡚࠸ࡿ 1) 2)ࠋዉⰋ┴❧ᲄ㝔㸦௨ୗࠊᲄ㝔㸧ࢆཷデࡍࡿᝈ⪅ ࡽ᳨ฟࡉࢀࡓ⭠ෆ⣽⳦⛉⣽⳦ࡶእ࡛ࡣ࡞ࡃࠊ≉ᇶ㉁≉␗ᛶᣑᙇᆺș-ࣛࢡࢱ࣐࣮ࢮ 㸦extended spectrum ș- lactamase; ESBL㸧ࢆ⏘⏕ࡍࡿ⸆⪏ᛶ⭠⳦ࡢศ㞳⋡ࡀᖺࠎቑ ຍࡋ࡚࠸ࡿࠋESBL ࡣ࣌ࢽࢩࣜࣥ⣔ࠊࢭࣇࣟࢫ࣏ࣜࣥ⣔࡞୍⯡デ⒪࡛ᗈࡃ⏝ࡉࢀࡿᢠ ⳦⸆ࢆຍỈศゎࡍࡿ㓝⣲࡛࠶ࡾࠊࣉࣛࢫ࣑ࢻࡀ᥋ྜఏ㐩ࡼࡾ⳦✀ࢆ㉺࠼࡚ᣑᩓࡍࡿࡓࡵ 㝔ෆឤᰁᑐ⟇࠾࠸࡚ࡶ㠀ᖖ㔜せ࡛࠶ࡿࠋࡑࡇ࡛ᮏ◊✲࡛ࡣࠊᲄᆅᇦ࠾ࡅࡿ ESBL ⏘⏕⭠⳦ࡢ≉ᚩࢆᢕᥱࡋࠊᆅᇦ࠾ࡅࡿᾐ㏱⋡ࠊ⏤᮶ᝈ⪅ࡢ⫼ᬒࠊឤཷᛶࣃࢱ࣮ࣥ࡞ ࢆゎᯒࡋఏᵝᘧࢆ᫂ࡽࡍࡿࡇࢆ┠ⓗࠊᲄ㝔࡛ศ㞳ࡉࢀࡓ⭠⳦ࡘ࠸࡚ศ ᏊᏛⓗㄪᰝࡋࡓࠋ ࠙◊✲ࡢᚲせᛶࠚ ⪏ᛶ⳦ศ㞳⋡ࡢྜࡸࠊᆅᇦูࡢ≉ᚩࢆ᫂ࡽࡍࡿࡇ࡛ࠊධ㝔ᝈ⪅࠾ࡅࡿึᮇᢞ ᢠ⏕ࡢ㑅ᢥࡀ㐺ṇࡉࢀࡿ⪃࠼ࡽࢀࡿࠋࡲࡓࠊᏛ⾡㞟➼࡛Ⓨ⾲ࡍࡿࡇࡼࡾࠊ ᆅᇦ࠾ࡅࡿ⪏ᛶ⳦ὶ⾜ࡢ≧ἣࢆၨⓎࡍࡿࡇࡀ࡛ࡁࡿࠋࡑࡢ⤖ᯝࠊ⪏ᛶ⳦ឤᰁࡣ 㐺ษ࡞ᢠ⏕ࡀ༑ศ㔞ᢞࡉࢀࠊせ࡞ᢠ⏕ᢞࡣ᥍࠼ࡽࢀ࡚᪂ࡓ࡞⪏ᛶ⳦ࡢฟ⌧ࢆᢚ ࠼ࡽࢀࡿࡇࡀᮇᚅࡉࢀࡿࡶࠊESBL ឤᰁ࡛ࡢ⮴Ṛ⋡ࡢపୗᐤ࡛ࡁࡿᮇᚅࡉ ࢀࡿࠋ ࠙◊✲ィ⏬ࠚ 2015 ᖺ 4 ᭶ࡽ 2016 ᖺ 3 ᭶ࡢ㛫ࠊᲄ㝔࠾࠸࡚ឤᰁࡀࢃࢀ࡚ᥦฟࡉࢀࡓ⮫ᗋ ᳨య㸦ၻ⑱ࠊ⾑ᾮࠊᒀ㸧ࡽ⭠⳦ࡀศ㞳ࡉࢀࡓಖ᭷⪅ࢆᑐ㇟ࡋࡓࠋ⭠⳦ࡢྠᐃ⸆ ឤཷᛶࡣ MicroScan auto SCAN4㸦Beckman coulter㸧ࢆ⏝࠸࡚⾜ࡋࡓࠋ࡞࠾ࠊ⸆ឤ ཷᛶヨ㦂ࡣ௨ୗࡢᢠ⏕ᑐࡋ࡚⾜ࡗࡓ㸦ABPCࠊABPC/CVAࠊPIPCࠊPIPC/TAZࠊCTXࠊ CAZࠊCFPMࠊAZTࠊLVFXࠊSTࠊMINOࠊGMࠊCMZࠊFOMࠊIPMࠊMEPM㸧ࠋྠᶵჾ 㸫 163 㸫 ࡢ ESBL ࢫࢡ࣮ࣜࢽࣥࢢᇶ‽ࡣ MICӍ8μg/ml 㸦Cefpodoxime㸧ࠊMICӍ4μg/ml (Ceftazidime, Aztreonam, Cefotaxime, Ceftiaxone)࡛࠶ࡾࠊࡇࢀヱᙜࡍࡿሙྜࡣ㆙࿌ࡀ⾲♧ࡉࢀࡿࠋ㆙ ࿌ࡀ⾲♧ࡉࢀࡓᰴᑐࡋ࡚ Double disk ἲࢆ⏝࠸࡚ ESBL ⏘⏕ࡢ☜ㄆࢆ⾜ࡗࡓࠋDouble disk ἲ࡛ ESBL ⏘⏕ࡀ☜ㄆࡉࢀࡓᰴࡣࠕESBL ᰴࠖࡋ࡚࣐ࢡࣟࣂࣥࢡಖᏑࡋࠊྠἲ ࡛ ESBL ⏘⏕ࡀ☜ㄆ࡛ࡁ࡞ࡗࡓᰴࡣࠕ⪏ᛶᰴࠖࡋ࡚ྠᵝ࣐ࢡࣟࣂࣥࢡಖ⟶ࡋࡓࠋ ྠ୍ே≀ࡽ⮫ᗋ᳨యࡀ」ᩘᅇ᥇ྲྀࡉࢀࠊESBL ⏘⏕⭠⳦ࡀ」ᩘ᳨ฟࡉࢀࡓሙྜࡣࠊ௦⾲ ᰴࡢࡳࢆಖᏑࡋࡓࠋಖᏑࡋࡓ⳦ᰴࡣ࡚ PCR ࢆ⏝࠸࡚ ESBL 㑇ఏᏊ㸦blaCTX, blaTEM, blaSHV㸧 ࡢ᭷↓ࢆㄪᰝࡋࡓ 3)ࠋESBL 㑇ఏᏊಖ᭷ᰴ㛵ࡋ࡚ࡣࠊࡑࡢ⏤᮶ᝈ⪅㛵ࡋ࡚௨ୗࡢሗ ࢆㄪᰝࡋࡓ㸹ᖺ㱋ࠊᛶูࠊ⏕άࡢሙࠊ⏤᮶᳨యࠊ㉳⅖⳦ࡋ࡚⒪ࡉࢀࡓࠊ⒪⏝࠸ ࡽࢀࡓᢠ⏕ࡣఱࠊධ㝔ᮇ㛫ࠊணᚋࠋศ㞳ࡉࢀࡓ⭠⳦࠾ࡅࡿ ESBL ⏘⏕ᰴࡢྜࢆ ㄪᰝࡋࠊ㝔ෆឤᰁᑐ⟇ࢧ࣮࣋ࣛࣥࢫ㸦Japan nosocomial infectious surveillance; JANIS㸧 ࡢࢹ࣮ࢱẚ㍑ࡋࡓࠋ࡞࠾ࠊᮏ◊✲ࡣᲄ㝔ࡢ⌮ጤဨ࡚ᢎㄆࢆཷࡅࡓ㸦ཷ␒ྕ H27-1㸧ࠋ ࠙ᐇෆᐜ࣭⤖ᯝࠚ ᑐ㇟ᮇ㛫ෆ 281 ᰴࡢ⭠⳦ࡀ 221 ேࡢᝈ⪅ࡽ᳨ฟࡉࢀࡓࠋࡑࡢ࠺ࡕ 56 ᰴࡀ MicroScan auto SCAN4 ࡼࡗ࡚ ESBL ࡢ⏘⏕ࢆࢃࢀࡓࠋྠ୍ே≀ࡽ᳨ฟࡉࢀࡓሙྜ ࡣ௦⾲ᰴࡢࡳࢆಖᏑࡋࡓࡓࡵࠊ᭱⤊ⓗ 37 ᰴࡢ⭠⳦ࢆಖᏑࡋࡓࠋࡇࡢ࠺ࡕࠊ30 ᰴࡀ Double disk ἲ࡛ ESBL ⏘⏕⳦ุᐃࡉࢀࠊ7 ᰴࡣ Double disk ἲ࡛ ESBL 㠀⏘⏕ุ᩿ࡉࢀࡓࠋ PCR ࡛ࡣࠊ๓⪅ࡣᰴ࠾࠸࡚ ESBL 㑇ఏᏊࡀ᳨ฟࡉࢀࠊᚋ⪅ࡣ 3 ᰴ࠾࠸࡚ ESBL 㑇ఏ Ꮚࡀ᳨ฟࡉࢀࡓࠋ᳨ฟࡉࢀࡓ⭠⳦࠾ࡅࡿ ESBL ⏘⏕ᰴࡢྜࡣ 15.4㸣࡛࠶ࡗࡓࠋ ࡲࡓࠊESBL 㑇ఏᏊಖ᭷⭠⳦ࡢಖ⳦⪅ 33 ྡࡢ࠺ࡕࠊ┿㉳⅖⳦ࡋ࡚⒪ࡉࢀࡓࡢࡣ 23 ྡ࡛࠶ࡗࡓࠋᕷ୰Ⓨࡣ 14 ࠊ㝔ෆⓎࡣ 9 ྡ࡛࠶ࡗࡓࠋᕷ୰Ⓨࡢ࠺ࡕタධᡤ୰ ࡢᝈ⪅ࡣ 11 ྡ࡛ࠊࡀእ᮶᳨࡛యࢆ᥇ྲྀࡉࢀࠊࡑࡢࡲࡲධ㝔ຍ⒪ࢆ࠺ࡅࡓࠋࡇࡢ࠺ࡕࡢ 7 ྡࡣྠ୍タධᡤࡋ࡚࠸ࡓࠋṧࡾࡢ 3 ྡࡣ⮬Ꮿ࡛⏕άࡋ࡚࠾ࡾࠊእ᮶ຍ⒪ࢆཷࡅࡓࠋᕷ ୰Ⓨࡢ ESBL ⏘⏕⭠⳦ࡣ࡚ CTX-M-9 group ࡛࠶ࡾࠊTEM ࢆేࡏᣢࡘᰴࡀ㸱ࠊ SHV ࢆేࡏᣢࡘᰴࡀ㸯࠶ࡗࡓࠋ㝔ෆ࡛㉳⅖⳦ࡋ᳨࡚ฟࡉࢀࡓ ESBL ⏘⏕⭠⳦ࡣ 9 ࡛ࠊ1 ࡢࡳ CTX-M-1 group OXA ࢆేࡏᣢࡗ࡚࠸ࡓࠋṧࡾࡢ 8 ࡣ CTX-M-9 group ࡛࠶ࡾࠊ ࡑࡢ࠺ࡕ 2 ࡣ TEM ࢆేࡏᣢࡗ࡚࠸ࡓࠋ┿㉳⅖⳦ࡋ࡚⒪ࡉࢀࡓࡢࡣ 23 ྡࡽ᳨ฟ ࡉࢀࡓᰴࡢ⸆ឤཷᛶ㛵ࡋ࡚ࡣ⾲ࡲࡵࡓࠋ 㸫 164 㸫 ᢠ⳦⸆ 㻭㻮㻼㻯 㻭㻮㻼㻯㻛㻯㼂㻭 㻼㻵㻼㻯 㻼㻵㻼㻯㻛㼀㻭㼆 㻯㼀㼄 㻯㻭㼆 㻯㻲㻼㻹 㻭㼆㼀 㻸㼂㻲㼄 㻿㼀 㻹㻵㻺㻻 㻳㻹 㻯㻹㼆 㻲㻻㻹 㻵㻼㻹 㻹㻱㻼㻹 㻹㻵㻯 ⪏ᛶ⋡䠄䠂䠅 㻌㼚㻩㻟㻞 ᭱ᑠ ᭱ 䠚㻝㻢 䠄㻾䠅 㻝㻜㻜 䍺㻌㻤 䠄㻾䠅 㻝㻢 䠄䠥䠅 㻟㻜㻚㻠 䠚㻢㻠 䠄㻾䠅 㻝㻜㻜 䍺㻝㻢 䠄㻿㻕 㻜 䠚㻞 䠄㻾䠅 㻝㻜㻜 㻠 䠄㻾䠅 䠚㻤 䠄㻾䠅 㻝㻜㻜 㻤 䠄㻾䠅 䠚㻝㻢 䠄㻾䠅 㻝㻜㻜 㻠 䠄㻾䠅 䠚㻤 䠄㻾䠅 㻝㻜㻜 㻞 䠄㻿㻕 䠚㻠 䠄㻾䠅 㻤㻞㻚㻢 㻜㻚㻡 䠄㻿㻕 䠚㻞 䠄㻾䠅 㻟㻠㻚㻤 㻠 䠄㻿㻕 䠚㻤 䠄㻾䠅 㻝㻣㻚㻠 㻠 䠄㻿㻕 䠚㻤 䠄㻾䠅 㻝㻡 䍺㻝㻢 䠄㻿㻕 㻜 䍺㻠 䠄㻿㻕 㻜 䍺㻝 䠄㻿㻕 㻜 䍺㻝 䠄㻿㻕 㻜 ࠙⪃ᐹᚋࡢㄢ㢟ࠚ JANIS ࡼࡿࠊ2014 ᖺᗘ᳨ฟࡉࢀࡓ⭠⳦ࡢ⣙ 11.6%ࡀࢭࣇ࢛ࢱ࢟ࢩ࣒⪏ᛶ⭠⳦ ࡛࠶ࡗࡓࠋࡇࡢከᩘࡀ ESBL ⏘⏕⭠⳦࡛࠶ࡿ᥎ᐃࡍࡿࠊᲄᆅᇦ࠾ࡅࡿ ESBL ⏘⏕ᰴࡢ᳨ฟ⋡ࡣ 15.4%࡛࠶ࡿࡽࠊᲄᆅᇦ࡛ࡣ ESBL ⏘⏕ᰴࡢ᳨ฟ⋡ࡀ㧗࠸ഴྥ࠶ ࡿࡇࡀ♧၀ࡉࢀࡓࠋ≉ࠊESBL 㑇ఏᏊಖ᭷⭠⳦ࢆಖ⳦ࡋ࡚࠸ࡓ 33 ྡࡢ࠺ࡕࠊ10 ྡࡀ ྠ୍タࡽධ㝔ࡋ࡚࠸ࡓࠋࡲࡓࠊ3 ྡࡶูࡢྠ୍タࡽධ㝔ࡋ࡚࠸ࡓࠋESBL ⏘⏕ᰴࡀ ┿㉳⅖⳦ࡋ࡚⒪ࡉࢀࡓᕷ୰Ⓨឤᰁᝈ⪅ࡣ 14 ྡ࡛࠶ࡗࡓࡀࠊࡑࡢ࠺ࡕ 11 ྡࡀ タධᡤ୰ࡢᝈ⪅࡛࠶ࡾࠊ7 ྡࡣྠ୍タධᡤࡋ࡚࠸ࡓࠋ㧗㱋⪅ࡀ㞟ᅋ⏕άࢆ⾜࠺⚟♴タ ࡛ࡣ⸆⪏ᛶ⳦ࡢỈᖹఏࡀ⏕ࡌࠊ⳦ࡢ ᗋ࡞ࡾ࠺ࡿࡇࡀሗ࿌ࡉࢀ࡚࠸ࡿࡀ 4)ࠊᡃࠎࡢ ㄪᰝ⤖ᯝࡣࠊᲄᆅᇦ࠾࠸࡚ࡶ⚟♴タࡀ⳦ࡢࣜࢨ࣮ࣂ࣮࡞ࡗ࡚࠸ࡿྍ⬟ᛶࢆ♧၀ࡍ ࡿࡶࡢ࡛࠶ࡗࡓࠋ ᲄ㝔᳨࡛ฟࡉࢀࡓ ESBL ⏘⏕⭠⳦ࡢᢠ⳦⸆ᑐࡍࡿឤཷᛶࡽࡣࠊ࢝ࣝࣂ࣌ࢿ࣒ ⣔ᢠ⳦⸆ᑐࡋ࡚ 100㸣ឤཷᛶࡀ࠶ࡾࠊ࢟ࣀࣟࣥ⣔ᢠ⳦⸆ᑐࡋ࡚ࡣ 100㸣⪏ᛶ࡛࠶ࡿࡇ ࡀࢃࡗࡓࠋࡲࡓࠊࢭࣇ࣓ࢱࢰ࣮ࣝࡣ 100㸣ࡢឤཷᛶࠊ࣍ࢫ࣐࣍ࢩࣥᑐࡋ࡚ࡣ 100㸣ࡢ ឤཷᛶࢆ♧ࡋࡓࠋESBL ⏘⏕⭠⳦ࡢ⳦⾑ᑐࡍࡿࢭࣇ࣓ࢱࢰ࣮ࣝࡢ᭷ຠᛶࢆሗ࿌ࡋࡓ◊ ✲ࡶ࠶ࡿࡓࡵ 5)ࠊESBL ⏘⏕⭠⳦ࡀཎᅉᚤ⏕≀ࡋ࡚㉳ࡉࢀࡓሙྜࡢ⒪⸆ࡋ࡚ࠊ࢝ ࣝࣂ࣌ࢿ࣒⣔ᢠ⳦⸆ຍ࠼࡚ࢭࣇ࣓ࢱࢰ࣮ࣝࡶೃ⿵࡞ࡾ࠺ࡿ⪃࠼ࡽ࠼ࡿࠋࡑࡢ㏫ࠊ ཎᅉᚤ⏕≀ࡋ࡚ ESBL ⏘⏕⭠⳦ࡀᐃࡉࢀࡓሙྜࡣࠊ࢟ࣀࣟࣥ⣔ᢠ⳦⸆ࡸࢭࣇࣟ ࢫ࣏ࣜࣥ⣔ᢠ⳦⸆ࢆ➨୍㑅ᢥࡍࡿࡇࡣ㑊ࡅࡿࡇࡀᏳ࡛࠶ࡿࡇࡀ♧၀ࡉࢀࡿࠋ ᚋࡢㄢ㢟ࡋ࡚ࠊᮏ◊✲ࡣᲄ㝔᳨࡛ฟࡉࢀࡓ⭠⳦ࢆᑐ㇟ࡋ࡚⾜ࡗࡓࡓࡵࠊྛ タ࠾ࡅࡿ⪏ᛶ⳦ಖ᭷⋡ࡀ⟬ฟ࡛ࡁ࡞࠸ࠋ࠶ࡿ≉ᐃࡢタධᡤࡋ࡚࠸ࡿ⏝⪅ࡀឤᰁ 㸫 165 㸫 ⨯ᝈࡋࡓሙྜࠊESBL ⏘⏕⭠⳦ࢆᛕ㢌࠾࠸ࡓᑐฎࡀᮃࡲࡋ࠸ࡇࡣ♧၀ࡉࢀࡓࡶࡢ ࡢࠊࡢ⛬ᗘ㓄៖ࡍࡁᮍࡔ᫂ࡽ࡛ࡣ࡞࠸ࠋࡲࡓࠊᮏ◊✲࡛ࡣࣃࣝࢫࣇ࣮ࣝࢻࢤࣝ 㟁ẼὋືࢆ⾜ࡗ࡚࠸࡞࠸ࠋࡑࡢࡓࡵࠊྛᰴ㛫ࡢ┦ືᛶࡢ᳨ウࡀ࡛ࡁࡎࠊタෆ࡛ఏࡋ࡚ ࠸ࡿุ᩿࡛ࡁ࡞࠸ࠋᚋࡣࠊ࠶ࡿタࡢ⏝⪅ࢆᑐ㇟ࡋࠊESBL ⏘⏕⭠⳦ࡢಖ᭷⋡ ࢆ⟬ฟࡍࡿࡶࡑࡢᗈࡀࡾࢆ⤒ⓗࣉࣟࢵࢺࡋࠊᰴ㛫ࡢ┦ྠᛶࢆㄪᰝࡍࡿࡇࡀᮃ ࡲࢀࡿࠋࡑࡋ࡚ࠊࡇࡢ⤖ᯝࢆᆅᇦࡢ㛤ᴗ་ࡸົ་ࡀ㞟ࡲࡿ◊✲࡛බ⾲ࡋࠊ⭠⳦ࡀឤ ᰁࡢ㉳⅖⳦㉳ࡉࢀࡓሙྜࡢึᮇ⒪࠾ࡅࡿᢠ⏕㑅ᢥ㛵ࡍࡿᥦゝࢆ⾜࠸ࠊᐇ⮫ ᗋࡢ㑏ඖࢆ⾜ࡗ࡚࠸ࡃᚲせࡀ࠶ࡿࠋ 㸦ཧ⪃ᩥ⊩㸧 1) Ben-Ami R, et al: A multinational survey of risk factors for infection with extended-spectrum ǃ-lactamase-producing enterobacteriaceae in nonhospitalized patients. Clin Infect Dis 49: 682-690, 2009. 2) Yamamoto A: Extended-spectrum ǃ-lactamase (ESBL)-producing Escherichia coli is frequently detected as a pathogen of urinary tract infection in nursing home residents. Nihon Ronen Igakkai Zasshi 48: 530-538, 2011. 3) Yano H, et al: Molecular characteristics of extended-spectrum ǃ-lactamases in clinical isolates from Escherichia coli at a Japanese tertiary hospital. PLoS ONE 8, e64359, 2013. 3) Doi Y, et al: The role of horizontal gene transfer in the dissemination of extended-spectrumǃ-lactamase-producing Escherichia coli and Klebsiella pneumoniae isolates in an endemic setting. Diagn Microbiol Infect Dis 74: 34-38, 2012. 4) Mataumura Y, et al: Multicenter retrospective study of cefmetazole and flomoxef for treatment of extended-spectrum-ǃ-lactamase-producing Escherichia coli bacteremia. Antimicrob Agents Chemother 59: 5107-5113, 2015. ࠙⤒㈝㏵᫂⣽ࠚ ࣐ࢡࣟࣂࣥࢡ㸦࣡࢟㸧 ࣑࣮࣮ࣗࣛࣄࣥࢺࣥᇵᆅ㸦ᰤ◊㸧 (6%/ ☜ㄆヨ㦂⏝ࢹࢫࢡ㸦ᰤ◊㸧 ⁛⳦ὸᆺ 1 ࢩ࣮ࣕࣞ㸦᪥Ỉ㸧 ᚤ㔞ᾮయ⸆ឤཷᛶࣉ࣮ࣞࢺ㸦ᰤ◊㸧 ᾘ⪖ရ㈝㸦ᩥල࣭ࢥࣆ࣮⏝⣬࣭ࣥࢡ௦㸧 ྜ ィ ྠ⏕ཌ⏕ᴗᅋຓᡂ㔠 㸫 166 㸫
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