B Y T TRNG I HC DC H NI HONG TH VN KHO ST TNH HNH S DNG KHNG
SINH TRN BNH NHN VIM MNG NO M TI KHOA TRUYN NHIM BNH VIN 103 KHA
LUN TT NGHIP DC S H NI- 2014 B Y T TRNG I HC DC H NI HONG TH VN KHO
ST TNH HNH S DNG KHNG SINH TRN BNH NHN VIM MNG NO M TI KHOA TRUYN
NHIM BNH VIN 103 KHA LUN TT NGHIP DC S Ngi hng dn: 1. PGS. TS Trnh
Th Xun Ha 2.ThS. Phan Th T Nh Ni thc hin: 1.B mn Y hc c s-trng i hc
Dc H Ni 2.Bnh vin 103 H NI 2014 LI CM N: Ti xin chn thnh cm n: -Ban
gim hiu trng i hc Dc H Ni to mi iu kin cho ti trong sut qu trnh hc
tp ti trng. -Cc thy c trong b mn Y hc c s cng cc thy c trc tip ging
dy tn tnh truyn t kin thc cho ti trong sut 5 nm qua. -Ban Gim c Bnh
vin Qun y 103 to iu kin thun li ti thc hin kha lun tt nghip. Ti xin
by t lng bit n su sc n: -PGS.TSTrnhThXunHachnhimbmnTruynnhim Bnh
vin Qun y 103 -ThS. Phan Th T Nh, b mn Y hc c s, trng i hc Dc H Ni
l nhng ngi thy trc tip du dt ti, tn tnh hng dn v ch bo cho ti nhiu
kin thc qu bu, ng gp nhng kin chn thnh cho ti trong sut thi gian
thc hin kha lun. Xin gi li cm n su sc ti gia nh, bn b, ngi thn lun
bn ti, chia s, ng vin v khch l ti trong sut thi gian qua. H Ni, ngy
14 thng 05 nm 2014 Sinh vin Hong Th Vn MC LC LI CM N MC LC DANH MC
BNG DANH MC HNH DANH MC K HIU, CH VIT TT DANH MC VIT TT TN VI KHUN
T VN
........................................................................................................
1 CHNG 1: TNG QUAN TI LIU
................................................................ 3
1.1.I CNG V BNH VIM MNG NO M
....................................... 3 1.1.1.Dch t hc bnh vim
mng no m
............................................................ 3
1.1.2.Cn nguyn vi khun gy bnh vim mng no m
..................................... 4 1.1.2.1. Haemophilus
influenzae
............................................................................
6 1.1.2.2. Neisseria meningitidis (No m cu)
........................................................ 6 1.1.2.3.
Streptococcus pneumoniae (Ph cu khun)
............................................ 6 1.1.2.4.Listeria
monocytogen
...............................................................................
7 1.1.2.5.Trc khun Gram m i kh (E.coli; Pseudomonas; Klebsiella)
......... 7 1.1.2.6.Group B Streptococcus agalatiae (Lin cu khun
nhm B) .................. 7 1.1.3.Triu chng ca bnh vim mng no m
.................................................... 7 1.1.3.1.
Triu chng lm sng
................................................................................
7 1.1.3.2.Triu chng cn lm sng
........................................................................
8 1.1.4.Chn on phn bit
......................................................................................
9 1.1.4.1. Chn on phn bit trc khi chc d dch no ty
............................... 9 1.1.4.2. Chn on phn bit sau khi
chc d dch no ty .................................. 9 1.1.5. Bin
chng, di chng ca bnh vim mng no m
.................................. 10 1.1.5.1. Bin
chng...............................................................................................
10 1.1.5.2. Di chng
..................................................................................................
11 1.2. I CNG V CC KHNG SINH S DNG TRONG IU TR BNH VIM MNG NO M
........................................................................................
11 1.2.1. Nguyn tc chung s dng khng sinh trong iu tr vim mng no m
11 1.2.2.Nguyn tc la chn khng sinh
............................................................... 12
1.2.3. Thi gian iu trkhng sinh
....................................................................
12 1.2.4. La chn khng sinh ban u theo kinh nghim
....................................... 12 1.2.5. La chn khng sinh
theo cn nguyn vi khun ........................................ 14
1.2.7. Cc nhm khng sinh iu tr vim mng no m
..................................... 16 CHNG 2: I TNG V PHNG PHP
NGHIN CU ................... 19 2.1. I TNG NGHIN CU
......................................................................
19 2.1.1. i tng nghin cu:
...............................................................................
19 2.1.2. Tiu chun la chn:
..................................................................................
19 2.1.3. Tiu chun loi tr:
....................................................................................
19 2.2. PHNG PHP NGHIN CU
.................................................................
19 2.2.1. Thit k nghin cu
....................................................................................
19 2.2.2. Phng tin nghin cu
.............................................................................
19 2.2.3. Phng php ly mu
.................................................................................
19 2.2.4. Ni dung nghin cu
..................................................................................
19 2.2.4.1. c im chung ca i tng nghin cu
............................................ 19 2.2.4.2. c im ca vi
khun gy vim mng no m...................................... 20
2.2.4.3. Kho st tnh hnh s dng khng sinh trn bnh nhn vim mng no m
.........................................................................................................................
20 2.2.5. Mt s quy c s dng trong nghin cu
................................................ 20 2.3. PHNG PHP X
L S LIU
............................................................. 21
CHNG 3: KT QU NGHIN CU
............................................................ 22
3.1. C IM CHUNG CA I TNG NGHIN CU ......................... 22
3.1.1. c im chung ca bnh nhn trong nghin cu
..................................... 22 3.1.2. Thi im mc bnh trong
nm
.................................................................
23 3.2. C IM VI KHUN GY VIM MNG NO M ........................... 24
3.2.1. Xt nghim tm vi khun
............................................................................
24 3.2.2. c im vi khun phn lp c
.............................................................. 24
3.2.3. Tnh hnh khng khng sinh ca vi khun gy bnh
............................. 25 3.3. KHO ST TNH HNH S DNG KHNG
SINH TRONG IU TR VIM MNG NO M
.....................................................................................
27 3.3.1. Tnh hnh s dng khng sinh trc khi nhp vin
................................... 27 3.3.2. Danh mc cc loi khng
sinh c s dng trong iu tr vim mng no m
......................................................................................................................
27 3.3.3. Kho st vic la chn phc khng sinh trong iu tr vim mng no m
......................................................................................................................
30 3.3.3.1. Phc iu tr khi u khi cha c kt qu cy khun
...................... 30 3.3.3.2. Phc iu tr thay th khi c kt qu cy
khun ................................ 32 3.3.3.3. nh gi vic la chn
khng sinh ban u trong iu tr vim mng no m da trn kt qu khng sinh
............................................................... 35
CHNG 4: BN LUN
...................................................................................
36 4.1. C IM CHUNG CA I TNG NGHIN CU ......................... 36
4.1.1. c im chung ca bnh nhn trong nghin cu
..................................... 36 4.1.2. Thi im mc bnh trong
nm
.................................................................
37 4.2. C IM VI KHUN GY VIM MNG NO M ........................... 37
4.2.1. Xt nghim tm vi khun
............................................................................
37 4.2.2. c im vi khun ca qun th phn lp c
........................................ 38 4.2.3. Tnh hnh khng
khng sinh ca mt s chng vi khun gy vim mng no m
..................................................................................................................
40 4.3. KHO ST TNH HNH S DNG KHNG SINH TRONG IU TR VIM MNG NO M
.....................................................................................
41 4.3.1. Tnh hnh s dng khng sinh trc khi nhp vin
................................... 41 4.3.2. Danh mc cc loi khng
sinh c s dng trong iu tr vim mng no m
......................................................................................................................
42 4.3.3. Kho st vic la chn cc phc khng sinh trong iu tr vim mng no
m
..................................................................................................................
44 KT LUN V XUT
.................................................................................
47 I. KT
LUN:......................................................................................................
47 1. c im ca bnh nhn:
.................................................................................
47 2. c im ca vi khun gy bnh:
....................................................................
47 3. Tnh hnh s dng khng sinh trong iu tr:
................................................... 47 II. XUT:
.......................................................................................................
48 TI LIU THAM KHO DANH MC BNG Tn bngTrang Bng 1.1. Cn nguyn vi
khun ph bin gy vim mng no5 Bng 1.2. Kt qu dch no ty trong mt s vim
mng no10 Bng 1.3. iu tr khng sinh theo kinh nghim i vi VMNM13 Bng
1.4. iu tr khng sinh c hiu i vi VMNM14 Bng 3.1: c im tui, gii tnh
ca bnh nhn VMNM v ng vo ca vi khun gy bnh 22 Bng 3.2: T l cy dch no
ty dng tnh24 Bng 3.3: Kt qu xt nghim nghim nui cy tm vi khun trong
DNT24 Bng 3.4: Tnh hnh s dng khng sinh trc khi nhp vin27 Bng 3.5:
Cc loi khng sinh c s dng28 Bng 3.6: T l cc phc n c khi u trong iu
tr VMNM31 Bng 3.7: T l cc phc phi hp khi u trong iu tr VMNM32 Bng
3.8: Phc thay th khi c kt qu cy khun m tnh33 Bng 3.9: Phc thay th
khi c kt qu cy khun dng tnh:35 Bng 3.10. T l ph hp ca cc phc khng
sinh ban u theo kt qu khng sinh 36 DANH MC HNH Tn biu Trang Hnh
3.1: Phn b bnh nhn theo thi im mc bnh trong nm23 Hnh 3.2: Tnh hnh
khng ca Streptococcus pneumonia25 Hnh 3.3: Tnh hnh khng ca
Neisseria meningitidis26 Hnh 3.4: Tnh hnh khng khng sinh ca
Streptococcus suis II26 DANH MC K HIU, CH VIT TT CSCng s DNTDch no
ty HRMMNHng ro mch mu no KSKhng sinh TMCTnh mch chm Tr TMTruyn tnh
mch UUng VMNMVim mng no m WHOT chc y t th gii (World Health
Organization) DANH MC VIT TT TN VI KHUN E.coliEschericiae coli H.
influenzaeHaemophilus influenzae K. pneumoniaeKlebsiella pneumoniae
L. monocytogenListeria monocytogen N. meningitisisNeisseria
meningitidis S. agalactiae Streptococcus agalactiae S.
aureusStaphylococcus aureus S. epidermidisStaphylococcus
epidermidis S. pneumoniaeStreptococcus peumoniae 1 T VN Vim mng no
l biu hin ca cc phn ng bo v ca c th chng li s xm nhim ca cc loi vi
khun vo h thn kinh trung ng. Cc phn ng vimdn n sto m(vi khun vt bo
cht)nnthng cgilvim mng no m (VMNM). VMNM c xp vo nhm mi bnh nhim
trng gy tvonghngutrnthgii.Theoctnh,minmthgiickhong1,2 triu ngi mc
VMNM [25], [43], v t l t vong do VMNM khong 20-25% [32], [36].VMNM
l mt trong nhng bnh nhim trng cp tnh quan trng nht ca
hthnkinhtrungng-lmtcpcunikhoa,cnthitphiciutr sm v tch cc [3], [6],
[26], [36]. Vic s dng khng sinh thch hp ng mt
vaitrhtscquantrngtrongiutrVMNM[3],[5],[24]lmgimc nguy c t vong xung
di 15% cng nh cc di chng thn kinh nng n.Tuy
nhin,trongvithpkqua,tltvongngilndoVMNMvnkhng gim, c l do thc trng s
dng khng sinh hin nay ang l mt vn ht sc ng bo ng.N ang lm gia tng t
l khng thuc ca vikhunni chung v vi khun gy VMNM ni ring. V vy, vic
kho st tnh hnh s dng khng sinh trong iu tr VMNM l rt cn thit.Lmt
bnh vin thc hnh ca Hc vin qun y, Bnh vin 103 lbnh
vinakhoahngI,viquymhn1000gingbnhthamgiavocngtc khm, cha bnh theo
tuyn v khu vc cho b i, cc i tng chnh sch, v nhn dn; phc v nhu cu iu
tr cho mt s lng ln bnh nhn t tuyn di chuynthngln(trongckhoaAM5-khoa
truynnhim).Nhmtmhiu 2 thc trng s dng khng sinh trong iu tr VMNM, t
nh gi tnh hp l trong s dng khng sinh trn cc i tng ny v c ci nhn tng
quan v iu trbnhVMNMtikhoatruynnhim,chngtitinhnhtinghincu Kho st tnh
hnh s dng khng sinh trn bnh nhn vim mng no m ti khoa truyn nhim bnh
vin 103 vi hai mc tiu sau: 1.Xc nh cc chng vi khun gy vim mng no m
v tnh hnh khng khng sinh ca chng ti khoa truyn nhim - Bnh vin 103.
2.Kho st vic s dng khng sinh trong iu tr vimmng no m ti khoa truyn
nhim - Bnh vin 103. 3 CHNG 1: TNG QUAN TI LIU 1.1.I CNG V BNH VIM
MNG NO M 1.1.1. Dch t hc bnh vim mng no m VMNM l hin tng vim ca cc
mng bao bc xung quanh h thn kinh
trungngdoccvikhunxmnhpvomngno,gyramtpngtng bchcua nhnvprotein trong
dch noty(DNT)[3],[5],[17],[36].Phn ng vim ny c th xy ra t no b n ty
sng, nh hng c mng nhn v mng nui, gy tng p lc ni s [38], mt nhn thc
v c th dn n nhng binchngthnkinhmntnh,thmchtvong.Chonnay,VMNMvnl mt
nguyn nhn quan trng gy bnh tt v t vong trn ton th gii [17], [36].
Hn1,2triutrnghpVMNMcctnhxyratrntonthgii mi nm [25], [43]. T l mc
bnh v t vong ca bnh VMNM khc nhau ty theo tng vng, quc gia, nhm tui
v c bit l tc nhn gy bnh. Nu khng iu tr, t l trng hp t vong c th cao
n 70%, v 20% nhng ngi sng st c th li di chng vnh vin bao gm mt thnh
gic, khuyt tt thn kinh, hoc mt mt chi [40].
TheosliuthngkchnhthctiM,hngnmtlmcVMNMl
10/100000dn[6],[30].ccncangphttrin,bnhcxuhngtrm trng hn, t l mc bnh
c th cao gp 10 ln so vi cc nc pht trin [21]. Bnh thng bng pht thnh
dch vo ma kh, nng. c bit chu Phi, trong 10 nm va qua c hn 700.000
trng hp VMNM v T chc Y t th gii (WHO)ctnhcnphimt10triueurongncn
dchbnh bngpht vnhaivimmngnogm18qucgiachuPhitriditngEthiopia n ty
Senegan. 4 VitNam,khngctrndchVMNMnoln,tuynhinbnhkhph bin. Theo bo
co ca Vin V sinh dch t trung ng, trong 3 thng u nm 2013 c nc c 352
trng hp VMNM, t l t vong khong 2% [6], trong hn 50 bnh nhn c nguyn
nhn l lin cu ln (Streptococcus suis). 1.1.2. Cn nguyn vi khun gy
bnh vim mng no m Nhiu vi khun c th gy VMNM, tuy nhin, tn sut mc ca
tng chng vikhuntythucvolatuicngnhmtsyutlinquannsc khng ca c th bnh
nhn [3]. Da theo cc nghin cu, ngi ta xc nh c c t nht 14 loi vi khun
l cn nguyn gy VMNM, trong ba loi vi khun hay gp nht l:
Streptococcus pneumoniae, Haemophilus influenzae v Neisseria
meningitis, chim 80% cc trng hp mc bnh [3], [6], [32]. 5 Bng 1.1.
Cn nguyn vi khun ph bin gy vim mng no [3], [12], [13] Yu tVi khun
ph bin Tui 0 - 4 tun Streptococcus agalactiae; E.coli; Listeria
monocytogenes; Klebsiella pneumonia; Enterococcus spp; Salmonella
spp 4 - 12 tun S.agalactiae;E.coli;L.monocytogenes;H.influenzae;
S.pneumoniae; N.meningitidis 3 thng n 18
tuiH.influenzae;N.meningitidis; S.pneumoniae18 - 50
tuiS.pneumoniae; N.meningitidis; Streptococcus suis > 50 tui
S.pneumoniae;N.meningitidis;L.monocytogenes;trc khun Gram (-) hiu
kh Cc yu t khc Tn thng min dch
S.pneumoniae;N.meningitidis;L.monocytogenes;trc
khunGrammhiukh(baogmcPseudomonas aeruginosa) V nn sS.pneumoniae;
H.influenzae; lin cu tan mu nhm A, B Chn thng s no, sau PT thn kinh
Staphylococcusaureus,Staphylococcusepidermidis,trc
khunGrammhiukh(baogmcPseudomonas aeruginosa) Thng dch no ty
S.epidermidis;S.aureus;trckhunGrammhiukh (bao gm c Pseudomonas
aeruginosa) H bch cu Trc khun Gram m hiu kh (bao gm c
P.aeruginosa), S.aureus 6 1.1.2.1. Haemophilus influenzae
H.influenzaelvikhunGram(-),cvaitrgybnhquantrngtrong VMNM do c c lc
cao. VMNM do H.influenzae chim khong 45-48% tng s bnh nhn VMNM, t l
t vong 3-6%. Trc y, H.influenzae l cn nguyn gy VMNM chnh cho tr em
di 6 tui, c bit l tr 6-12 thng, vi t l mc
31/100.000dn.Hinnay,VMNMdoH.influenzaegimnhiudothchin tim chng thng
xuyn vi vaccin Hib lin hp. T lmcbnh gim hn 50% v ph bin ngi ln hn l
tr em [18], [30], [45], [49]. 1.1.2.2. Neisseria meningitidis (No m
cu) N. meningitidis l cu khun Gram (-), ch gy bnh ngi. No m cu c 12
tp huyt thanh c xc nh, da vo polysaccharide ca vch t bo vi
khun,trong 6tphuytthanhc vaitr gybnh lA,B,C,W135,X,Y.
VMNMdonomcuchyugptremdi5tuivthanhthiunin. Bnh c th gy thnh dch ln
do ng ly truyn ch yu l ng h hp. T l mc VMNM do no m cu cao nht khu
vc chu Phi. Trn vnh ai vim mng no, t nht 350 triu ngi c nguy c mc
bnh trong nhng v dch xy ra hng nm. tr s sinh, him gp VMNM do no m
cu [39], [45], [48]. 1.1.2.3. Streptococcus pneumoniae (Ph cu khun)
S.pneumoniae l cu khun Gram (+). y l cn nguyn gy bnh VMNM ph bin
ngi trng thnh v mt trong ba cn nguyn chnh tr em. T l vim nng no m
do ph cu vo khong 1 - 3/1000 dn. Tuy nhin, VMNM do
phcutkhigythnhdchln.Bnhcththayitheoma,nhngthng gia mang
ctlmcbnhcaonhttrongnm.Phcuthngctr ng h hp trn ca ngi khe mnh. Khi
gp iu kin thun li, vi khun s 7
xmnhpvohtunhongynhimkhunhuytvtrnvomngnogy VMNM [2], [14], [30].
1.1.2.4.Listeria monocytogen
LmttrckhunGram(+)sngksinhnibo,haygybnhtrs
sinhvnhngtrnghpsuygimmindch.TlVMNMdoListeria
monocytogenchimkhong2%.PhnmangthaicthmangListeria monocytogen b phn
sinh dc v c th truyn bnh cho con [19], [30], [46]. 1.1.2.5.Trc khun
Gram m i kh (E.coli; Pseudomonas; Klebsiella)
CctrckhunGram(-)nylcnnguyncanhiubnhnhimkhun nhng hay gp l vim ng h
hp v VMNM tr em, c bit l tr s sinh. Tl t vong tng i cao v cc cn
nguyn ny khng khngsinhrtmnh. [30], [45], [51]. 1.1.2.6.Group B
Streptococcus agalatiae (Lin cu khun nhm B)
LvikhunGram(+),thngctrngsinhdcdicamv truyn sang cho con trong thi k
mang thai hoc khi chuyn d. T l mc bnh caonhng tr sinhnon
haytrcmvism,thi gianchuynd ko di [30], [45], [51]. 1.1.3. Triu chng
ca bnh vim mng no m1.1.3.1. Triu chng lm sngTy theo cn nguyn, vng a
l, thi k bnh, la tui khc nhau m triu
chngcaVMNMcnhngcimkhcnhau,trongccctriuchng chnh l hi chng nhim khun
v hi chng mng no nh sau:Hi chng nhim khun: 8 Thng khi pht t ngt. St
cao lin tc 39-40C, i khi st rt cao km theo rt run, co git. au u, au
mi c khp.Hi chng mng no: Thng pht trin nhanh, rm r, tng i y triu
chng: Triu chng cnng: au u d di; bun nn v nn d dng;to bn; s nh sng.
i vi tr nh thng b b, ng g, quy khc tng cn. Triu chng thc th: 3 du
hiu cng gy (+), kernig (+), brudzinski (+);
tremthngcduhiucmm,nmtthcsng;thptrc phng hoc cng. Cc biu hin khc: co
git, lit khu tr, h m, ban xut huyt hoi t hnh sao (VMNM do no m cu)
[3], [5], [6], [17], [36]. 1.1.3.2.Triu chng cn lm sng Dch no ty:
Xc nh chn on khi DNT c cc biu hin sau: Mu sc: mu m khi (sm) hoc l c
nh nc da, nc vo go. S lng t bo tng cao, t 100 n hng nghn t bo/ mm3,
trong bch cu a nhn trung tnh > 80%;nhiu t bo thoi ha, t bo m.
Nng Protein tng cao (1-2 g/lt). Nng Glucose gim thp, i khi ch cn
vt. Soi v cy DNT: c th phn lp c tc nhn gy bnh v lm khng sinh . 9 Cc
xt nghim khc: Cng thc mu: s lng bch cu tng cao, t l bch cu a nhn
trung tnh thng tng > 80%. Cy mu, cy dch cc nhim trng cng c th xc
nh c vi khun gy bnh [3], [5], [6], [17], [36]. 1.1.4. Chn on phn
bit 1.1.4.1. Chn on phn bit trc khi chc d dch no ty Cn phn bit VMNM
vi co git st cao, ng kinh, vim mng no do cn nguynvirus,do lao,do
ksinh trng.Trong nhng trnghpchaphnbit c hay c nghi ng VMNM, gii php
ng n nht vn l chc d DNT xc nh chn on [3], [5], [6], [17], [36].
1.1.4.2. Chn on phn bit sau khi chc d dch no ty Hu ht cc trng hp xt
nghim DNT in hnh cho php chn on xc nh hay loi tr chn on VMNM [3],
[5], [6], [17], [36]. 10 Bng 1.2. Kt qu dch no ty trong mt s vim
mng no [3] Mu scBch cuGlucoseProteinSoi tiCy DNT bnh thng Trong,
khng mu < 10/ml 1/2-2/3 glucose mu < 0,5 g/lm tnhm tnh VMNMc
Tng cao, a s BCNTT Gim nhiu Tng cao Nhum Gram (+) (+) VMN do lao
Trong/ Vng chanh Tng, a s lympho Gim nhTngAFB (+) VMN do nm Trong
hoc cTng, a s lympho Gim nhTng Nhum mc tu (+) VMN do virus Trong
Tng, a s lympho Bnh thng Bnh thng/ tng nh m tnhm tnh 1.1.5. Bin
chng, di chng ca bnh vim mng no m 1.1.5.1. Bin chng Tn thng dy thn
kinh s no: trong VMNM c th tn thng cc dy thn kinh s no nh dy II,
III, IV, VI, VII, VIII... p xe no, p xedi mng cng, t m dc huytqun,
vimtc tnh mch, vim quanh mch mu no... 11 Tc nghn dch no tu v dy dnh
mng no gy cn tr lu thng dch no tu, hi chng no nc.
Ngoiracnccbinchngngoihthnkinh,tutheocnnguynvi khun gy ra nh sc c t,
xut huyt ph tng (gp trong nhim khun
huyt,vimmngnodomngnocu),vimkhp,vimnitmmc, vim ngoi tm mc, vim thn,
vim phi[5], [6], [36]. 1.1.5.2. Di chng Lc, ic, cm, m, hi chng no
nc... Tn thng thn kinh khu tr gy lit (lit mt chi, lit na ngi, lit
hai chi di, tn thng dy thn kinh s no...) Gim tr nh, sa st tr tu, ri
lon tm thn... ng kinh [5], [6], [36]. 1.2.I CNG V CC KHNG SINH S
DNG TRONGIU TR BNH VIM MNG NO M [5], [6], [10] 1.2.1. Nguyn tc
chung s dng khng sinh trong iu tr vim mng no m iu tr cng sm cng
tt.S dng khng sinh ngay khi c chn on. Chn khng sinh da vo kinh
nghim (khi cha c kt qu cy khun) hoc theo cn nguyn vi khun v theo
khng sinh . 12 Trong cc trng hp bnh nng, cc bin php iu tr tch cc v
h tr l ht sc quan trng cu sng bnh nhn v hn ch cc bin chng [5], [6].
1.2.2.Nguyn tc la chn khng sinh Chn khng sinh theo mm bnh v theo
khng sinh . Khi cha r mm bnh, cn chn khng sinh c ph tc dng rng.
Khng sinh phiquachng romuno.Nukhngsinhkhuchtn km vo mng no nhng nhy
vi mm bnh th phi dng liu cao. Khng sinh dit khun phi t c nng dit
khun, bi vy lun phi dng ng tnh mch [3], [5], [12], [34]. 1.2.3. Thi
gian iu trkhng sinh Thi gian iu tr khng sinh ty theo p ng lm sng v
bin i DNT. Thi gian iu tr trung bnh khong 10-14 ngy.Ngng khng sinh
khi protein DNT < 0,5 g/l [3], [12]. 1.2.4. La chn khng sinh ban
u theo kinh nghim Khng sinh ban u theo kinh nghim c khuyn co theo
bng 3.1 di y: 13 Bng 1.3. iu tr khng sinh theo kinh nghim i vi VMNM
[3], [12], [28] Yu tKhng sinh Tui 0 - 4 tun Ampicillin kt hp vi
cefotaxim hoc ampicillin kt hp vi aminoglycosid 4 - 12
tunAmpicillin kt hp vi C3 3 thng n 18 tui C3 hoc ampicillin phi hp
vi chloramphenicol 18 - 50 tui C3 thm ampicillin nu nghi ng VMN do
L.monocytogens > 50 tuiAmpicillin phi hp vi C3 Cc yu t khc Tn
thng min dch Vancomycin phi hp vi ampicillin, ceftazidime V nn sC3
Chn thng s no, sau PT thn kinh Vancomycin phi hp vi ceftazidime
Thng dch no ty Vancomycin phi hp vi ceftazidime H bch cuVancomycin
phi hp vi ceftazidime hoc cefepim (Cephalosporin th h 3 (C3):
Cefotaxim hoc ceftriaxon) 14 1.2.5. La chn khng sinh theo cn nguyn
vi khun La chn khng sinh theo cn nguyn vi khun c tm tt bng 1.4 di
y: Bng 1.4. iu tr khng sinh c hiu i vi VMNM [3], [12], [13], [28]
Cn nguynKhngsinhla chn u tin Khng sinh thay th Haemophilus
influenza - lactamase (-)AmpicillinC3, cefepim, aztreonam,
chloramphenicol - lactamase (+)C3Cefepim, chloramphenicol,
aztreonam, fluoroquinolone Neisseria meningitidis Penicillin
MIC
