B Y T TRNG I HC DC H NI NGUYN TH LINH KHO ST VIC S DNGKHNG SINH TRN BNH NHNVIM PHI LIN QUAN N TH MY KHOA HI SC CP CU BNH VIN A KHOA C GIANG KHA LUN TT NGHIP DC S H NI - 2013 B Y T TRNG I HC DC H NI NGUYN TH LINH KHO ST VIC S DNG KHNG SINH TRN BNH NHN VIM PHI LIN QUAN N TH MY KHOA HI SC CP CU BNH VIN A KHOA C GIANG KHA LUN TT NGHIP DC S Ngi hng dn: 1. ThS. Cao Th Bch Tho 2. DS. Nguyn Thu Hng Ni thc hin: 1.B mn Dc lm sng 2.Bnh vin a khoa c Giang H NI - 2013 LI CM N Vi lng knh trng v bit n su sc, em xin by t lng bit n chn thnh n: ThS. Cao Th Bch Tho DS. Nguyn Thu Hng Nhng ngi thy dnh nhiu thi gian, cng sc tn tnh hng dn em trong sut qu trnh hc tp, nghin cu hon thnh kha lun ny. Em cng xin gi li cm n chn thnh nht ti: -Ban gim hiu, phng o to trng i hc Dc H Ni -Cc thy c trong b mn Dc lm sng -Cc bc s, cn b khoa Hi sc cp cu v cc cn b Phng lu tr bnh n Bnh vin a khoa c Giang nhittnhgipvtomiiukinchoemtrongqutrnhthchin ti. Em cng v cng bit n gia nh, bn b, ngi thn, nhng ngi lun gip , ng vin, quan tm n em trong cuc sng cng nh trong hc tp. Xin chn thnh cm n. H Ni, ngy 19 thng5nm 2011 Sinh vin Nguyn Th Linh MC LC LI CM N MC LC DANH MC CH VIT TT DANH MC BNG DANH MC HNH T VN ............................................................................................................. 3 CHNG 1. TNG QUAN ....................................................................................... 3 1.1.VIM PHI LIN QUAN N TH MY ............................................... 3 1.1.1.Khi nim vim phi lin quan n th my .......................................... 3 1.1.2.Dch t bnh vim phi lin quan n th my ...................................... 3 1.1.3.C ch bnh sinh v cc yu t nguy c ca VPTM .............................. 5 1.1.4.Chn on vim phi lin quan n th my ......................................... 7 1.1.5.Tc nhn gy bnh vim phi lin quan n th my ............................ 9 1.2.TNH HNH KHNG THUC CA CC VI KHUN HIN NAY ....... 11 1.3.IU TR VIM PHI LIN QUAN N TH MY ........................... 12 1.3.1.Nguyn tc iu tr vim phi lin quan n th my .......................... 12 1.3.2.La chn khng sinh ban u theo kinh nghim .................................. 13 1.3.3.La chn khng sinh theo cn nguyn vi khun hc ............................ 15 CHNG 2. I TNG V PHNG PHP NGHIN CU ........................ 17 2.1.I TNG NGHIN CU ..................................................................... 17 2.1.1.Tiu chun la chn .............................................................................. 17 2.1.2.Tiu chun loi tr ................................ Error! Bookmark not defined. 2.2.PHNG PHP NGHIN CU ............................................................... 17 2.2.1.Thit k nghin cu .............................................................................. 17 2.2.2.Phng php ly mu ........................................................................... 17 2.2.3.Phng php thu thp thng tin ............................................................ 17 2.2.4.Cc ch tiu nghin cu ........................................................................ 17 2.2.5.Mt s khi nim trong nghin cu ...................................................... 18 2.3.PHNG PHP X L S LIU ........................................................... 19 CHNG 3. KT QU ........................................................................................... 20 3.1.C IM CA BNH NHN ................................................................ 20 3.1.1.c im chung ca bnh nhn nghin cu ......................................... 20 3.1.2.Kt qu iu tr ..................................................................................... 21 3.1.3.Cc yu t nguy c ca VPTM ............................................................. 22 3.1.4.Phn loi bnh nhn theo VPTM sm v VPTM mun ....................... 22 3.2.CC TC NHN GY BNH VPTM ...................................................... 22 3.2.1.c im v xt nghim vi sinh v vi sinh vt gy bnh ..................... 22 3.2.2.Phn loi vi khun theo VPTM sm v VPTM mun .......................... 24 3.2.3.Tnh khng khng sinh ca mt s vi khun gy bnh thng gp ..... 25 3.3.KHO ST TNH HNH S DNG KHNG SINH TRONG IU TR VPTM .................................................................................................................... 27 3.3.1.Cc khng sinh c s dng ............................................................... 27 3.3.2.Cc liu php khng sinh c s dng ............................................... 28 3.3.3.La chn khng sinh theo thi im chn on VPTM ....................... 31 3.3.4.La chn khng sinh ban u trong iu tr VPTM ............................. 33 CHNG 4. BN LUN ........................................................................................ 35 4.1.C IM CA BNH NHN VPTM ................................................... 35 4.2.CN NGUYN GY VPTM ..................................................................... 36 4.3.TNH HNH KHNG KHNG SINH CA MT S VI KHUN GY BNH THNG GP ......................................................................................... 37 4.3.1.Tnh hnh khng khng sinh ca Acinetobacter baumannii ................. 37 4.3.2.Tnh hnh khng khng sinh ca Pseudomonas aeruginosa ................. 39 4.3.3.Tnh hnh khng khng sinh ca Klebsiella pneumoniae, E. coli ......... 40 4.4.TNH HNH S DNG KHNG SINH TRN BNH NHN VPTM .... 43 4.4.1.Tnh hnh s dng khng sinh trn bnh nhn VPTM .......................... 43 4.4.2.La chn khng sinh trong phc ban u iu tr VPTM ............... 44 KT LUN V XUT ...................................................................................... 47 1.KT LUN ..................................................................................................... 47 2. XUT ....................................................................................................... 48 PH LC TI LIU THAM KHO CC CH VIT TT VPTMVim phi lin quan n th my (Ventilator-associated pneumonia) MDRa khng thuc (Multidrug-resistant) COPDBnh phi tc nghn mn tnh (Chronic obstructive pulmonary disease) ARDSHi chng suy h hp cp tnh (Acute respiratory distress syndrome) MRSAT cu vng khng methicillin (Methicillin-resistant Staphylococcus aureus) ESBL -lactamase hot ph rng (Extended spectrum beta-lactamase) CPISim nhim trng phi trn lm sng (Clinical Pulmonary Infection Score) PCTProcalcitonin CRPProtein C phn ng BVBnh vin KSKhng sinh PPhc TKTWThn kinh trung ng C2GCephalosporin th h 2 C3GCephalosporin th h 3 C4GCephalosporin th h 4 FQFluoroquinolon DANH MC CC BNG STTK hiuTn bng 1Bng 1.1Cc yu t nguy c ca VPTM 2Bng 1.2Cc tc nhn gy VPTM3Bng 3.1Cc c im chung ca bnh nhn VPTM 4Bng 3.2Cc yu t nguy c mc VPTM 5Bng 3.3T l VPTM sm v VPTM mun 6Bng 3.4c im v xt nghim vi sinh v vi sinh vt gy bnh 7Bng 3.5Cc khng sinh c s dng trn bnh nhn VPTM 8Bng 3.6Cc phc 1 khng sinh c s dng 9Bng 3.7Cc phc phi hp 2 khng sinh c s dng 10Bng 3.8Cc phc phi hp 3 khng sinh c s dng 11Bng 3.9T l (%) cc phc khng sinh theo thi im chn on VPTM 12Bng 3.10T l (%) cc phc khng sinh thng gp nht theo thi im chn on VPTM 13Bng 3.11T l cc phc ban u trong iu tr VPTM sm v mun 14Bng 3.12T l ph hp ca cc phc khng sinh ban u theo kt qu khng sinh 15Bng 4.1T l (%) khng khng sinh ca A. baumannii trong mt s nghin cu 16Bng 4.2T l (%) khng khng sinh ca P. aeruginosa trong mt s nghin cu 17Bng 4.3T l (%) khng khng sinh ca K. pneumoniae trong mt s nghin cu 18Bng 4.4T l (%) tnh khng khng sinh ca E. coli trong mt s nghin cu DANH MC CC HNH STTK hiuTn hnh 1Hnh 3.1Kt qu iu tr ca bnh nhn VPTM 2Hnh 3.2T l cc tc nhn gy bnh theo VPTM sm v mun 3Hnh 3.3T l khng khng sinh ca A. baumannii v P. aeruginosa 4Hnh 3.4T l khng khng sinh ca K. pneumoniae v E. coli 5Hnh 3.5T l cc phc khng sinh trn bnh nhn VPTM 1T VN Th my l mt bin php hi sc quan trng iu tr cc bnh nhn nng. Tuy nhin, bin chng vim phi lin quan n th (VPTM) my kh thng gp, chim9-27%sbnhnhnthmy[35,59].VPTMlmkodithigiannm vin,tngchiphchmscsckhe,tngtltvongcabnhnhn[35,47]. Theo Alp E. v cng s, chi ph cho bnh nhn VPTM gp khong 3 ln so vi cc bnh nhn th my nhng khng mc vim phi [15]. Mc d, hin nay c nhiu tinbtrongviciutrkhngsinh,ccphngthcchmscbnhnhnv phng nga bnh tt hn nhng VPTM vn l mt trong nhng nguyn nhn quan trng gy bnh tt v t vong [62]. Vit Nam, nhiu nghin cu v VPTM c thc hin cc bnh vin khc nhau nh: bnh vin Bch Mai, bnh vin 103, bnh vin nhn dn Gia nh [2,6,8].Ktqu caccnghincunychothyvicsdngkhngsinhtrong iu tr VPTM vn cn l mt thch thc.Bnh vin a khoa c Giang l bnh vin a khoa khu vc hng I trc thuc SYtHNi,cngtrnkhuvcdncngc,phcvchonhucu iu tr ca mt s lng ln bnh nhn. Trong c rt nhiu bnh nhn nng cn iu tr tch cc v t l khng nh cc bnh nhn phi th my.Theo thng k s b, s lng bnh nhn th my ti khoa Hi sc cp cu bnh vin a khoa cGiangnm2012vokhong300bnhnhn.Trongkhi,tikhoaHisc cp cu - bnh vin a khoa c Giang vn cha c ti no nghin cu, nh gi y v VPTM. gp phn nng cao hiu qu iu tr v chm sc bnh nhn VPTM ti bnh vin a khoa c Giang, chng ti tin hnh ti nghin cu Kho st vic s dng khng sinh trn bnh nhn vim phi lin quan n th mykhoaHisccpcuBnhvinakhoacGiangvibamctiu sau: -MtcimcabnhnhnVPTMtikhoaHisccpcubnh vin a khoa c Giang. 2-MthnhnhcctcnhngybnhVPTMvmckhngkhng sinh ca cc vi khun gy bnh ph bin ti khoa Hi sc cp cu bnh vin a khoa c Giang. -MtccliuphpkhngsinhcsdngtrnbnhnhnVPTMti khoa Hi sc cp cu bnh vin a khoa c Giang. 3CHNG 1. TNG QUAN 1.1.VIM PHI LIN QUAN N TH MY1.1.1.Khi nim vim phi lin quan n th my Vim phi lin quan n th my l vim phi xut hin sau 48 -72 gi k t khi t ng ni kh qun hoc m kh qun [4, 36].VPTMcchiathnhVPTMkhiphtsmvVPTMkhiphtmun. Theo hng dn ca hip hi lng ngc Hoa K (2005), VPTM khi pht sm xy ra trong 4 ngy u nhp vin, thng c tin lng tt v c nhiu kh nng gy ra biccvikhunnhycmvikhngsinh.Ngcli,VPTMmunthngpht trin trong ngy th 5 hoc lu hn sau khi nhp vin, ch yu do cc vi khun a khng thuc v thng lin quan n vic tng t l t vong bnh nhn [59].1.1.2.Dch t bnh vim phi lin quan n th my 1.1.2.1. Tnh hnh vim phi lin quan n th my trn th gii T l mc VPTM VPTM l nhim trng mc phi ph bin nht ti khoa iu tr tch cc, t l mc VPTM t 6% n 52% [36]. T l ny c s dao ng ln gia cc nghin cu phthuctiuchunchnoncsdng,bnhvin,khoaiutrtchcc, qun th nghin cu [35, 36]. VPTM xy ra 9 27% bnh nhn th my [35, 59]. S bnh nhn mc VPTM tnh trn 1000 ngy th my t 13,2/1000 n 51/1000. SbnhnhnmcVPTMtnhtrn1000ngynmvinlt5bnhnhn/1000 ngybnhnhnnhin35bnhnhn/1000ngybnhnhnbng.Tlmc VPTM cc bnh nhn phu thut cao hn bnh nhn iu tr ni khoa [36]. T l mc VPTM tng ln theo thi gian th my. Nguy c mc VPTM trong nhngngyunmvinlcaonht,khong3%/ngytrong5ngyutinth my, 2%/ngy t ngy th 5 n ngy th 10 th my v 1%/ngy t nhng ngy sau [47, 59]. T l t vong bnh nhn VPTM 4TltvongbnhnhnVPTMdaongt20%n70%[36].Thng thng rt kh xc nh chnh xc t l t vong do VPTM v nh hng ca cc bnh mc km, tuy nhin, VPTM c cho l lm tng t l t vong ca cc bnh mckmlnkhong30%[52].Trongmtphntchmeta,AgrafiotisM.vcc cng s cng kt lun rng VPTM c lin quan n t l t vong cao hn bnh nhn iu tr tch cc (OR = 1,96, 95% CI = 1,26 - 3,04) [14].VictngtltvongnhngbnhnhnVPTMclinquannccvi khungybnhcbitlPseudomonasaeruginosavAcinetobacterspp.[59]. Tronghainghincukhcnhau,vimphidoP.aeruginosahocAcinetobacter spp. c t l t vong tng ng l 65% v 87% cao hn ng k so vi t l t vong ca VPTM do cc vi sinh vt khc (31-55%) [36]. Tng t nh vy, Athanassa Z. v cng s ch ra rng bnh nhn VPTM do MRSA c t l t vong th ti bnh vin v ti khoa iu tr tch cc cao hn so vi S. aureus nhy cm vi methicilin (ln lt OR = 1,79;95% CI = 1,21 - 2,65; OR = 2,49; 95% CI = 1,54 - 4,06) [17]. Tc ng kinh t ca VPTM TheoAlpE.vcngs,chiphchobnhnhnVPTMgpkhong3lnso vi cc bnh nhn th my nhng khng mc vim phi [15]. Mt nghin cu phn tch chi ph bnh nhn VPTM ti Th Nh K cng cho thy VPTM lm ko di thigiannmtikhoaiutrtchcc,tngthigianthmy,tngtngchph chmscsckhe(8602,75045,5laM)sovinhmbnhnhnthmy nhng khng mc vim phi (2621,92053,3 la M) (P < 0,0001) [38].1.1.2.2. Tnh hnh vim phi lin quan n th my ti Vit Nam Hin nay, ti Vit Nam, vn VPTM c quan tm. Nhiu ti nghin cu v vn ny c thc hin v mi bnh vin u c nhng thng k ring v tnh hnh VPTM ti bnh vin mnh. Theo nghin cu ca PhmHng Trng ti bnhvin175nm2009,tlmcVPTMl27,37%,tltvongbnhnhn VPTM l 32,65%, trong t vong do vim phi (14,29%) v t vong do nguyn nhnphihp(18,36%)[9].TibnhvinBchMai,theonghincucaGiang 5ThcAnh(2003-2004),VPTMchim64,8%vimphibnhvin,trongkhi, nghin cu ca Trn Hu Thng v cng s t thng 9/2009 n thng 8/2011 cho thytlmcVPTMl38,9%[1,8].Tibnhvin103,theoPhmThiDng (2009-2011), t l t vong bnh nhn VPTM l 23,81% trong t l t vong do VPTMl17,46%[6].TlmcVPTMsaumbnhvinnhndnGianh nm2009l46,48%,trong39,39%lVPTMkhiphtsmv60,61%khi pht mun, t l t vong bnh nhn VPTM l 33,33% [2]. 1.1.3.C ch bnh sinh v cc yu t nguy c ca VPTM Vim phi xy ra khi cc tc nhn gy bnh xm nhp v tn ti trong ng h hp di v nhu m phi bnh thng v khun ca bnh nhn [20, 42]. Thng thng, ng h hp c mt lot cc c ch bo v bao gm: hng ro gii phu (nhthanhmn,thanhqun),phnxho,dchtitphqun,hthngvinhung maobmt,cchthcbo,qu trnhopsonintrongphivhthngmindch qua trung gian t bo v dch th [20, 36]. Khi cc c ch bo v ny hot ng bnh thng s ngn chn s xm nhp ca vi khun, nhng khi cc c ch bo v ny b suy yu, vi sinh vt xm nhp c c tnh bt thng hoc c s xm nhp ca mt lng ln vi sinh vt th vim phi s xy ra [20]. Cc tc nhn gy bnh xm nhp vo ng h hp di thng qua 4 c ch: 1) ht phi cc dch tit cha vi sinh vt gy bnh hoc trc tip t hu hng hoc gin tip do tro ngc d dy vo vng huhngsauvonghhpdi;2)lynhimtccnhimtrngbn cnh nh mng phi; 3) ht phi khng kh hay kh dung nhim bn; 4) cc vi sinh vttccnhimtrngticccquantrongcththeongmuhocbch huyt vo phi [55]. Vic ht phi cc tc nhn gy bnh t khng kh hay kh dung nhim bn v ly nhim theo ng mu hoc cc nhim trng bn cnh l t ph bin [18, 59]. C ch quan trng nht dn n VPTM l ht phi cc dch tit cha vi sinh vt gy bnh hoc trc tip t hu hng hoc gin tip do tro ngc d dy vo vng hu hng sau vo ng h hp di [59]. 6-S xm nhp ca cc tc nhn gy bnh t hu hng: H vi sinh vt bnh thng hu hng ca bnh nhn khng t ni kh qun, khng mc bnh nng bao gm ch yu lin cu khun, Haemophilus spp. v cc vi khun k kh. Trong thi gian bnh nng, c bit l bnh nhn iu tr tch cc, hvisinhvthuhngthayingk:trckhunGrammhiukhvS. aureus chim u th [55]. Mt nghin cu chng minh c dch tit, nc bt hng i xung ng h hp, bng cch s dng xanh methylen cng nh cc cht ng v phng x. Khi cy khun dch hng v dch tit kh ph qun cho thy s gingnhauvvikhunphnlpc[37].Mtnghincukhccngchra rng 46% cc vi sinh vt c phn lp t kh qun c phn lp t hu hng trcy[55].Ccktqunyanktlunrngngunvikhunchnhgy VPTM l cc vi khun pht trin vng hu hng [37, 55]. -S xm nhp ca cc vi sinh vt t d dy: KhipHddygim(nhiutrbngthuckhngH2,thuccchbm proton)hoctngthngddystoiukinchosphttrincaccvi khun trong d dy. Cc vi sinh vt trong d dy c th tro ngc ln thc qun v c ht vo kh qun c bit l khi bnh nhn nm hoc t cc ng thng mi d dy, ming d dy [55].Victnikhquncnglmgiatngnguycvimphidotnikh qunlmtnthngbmtlpmngnhy,phvphnxh,toiukinht vo mt s lng nht nh cc vi khun t ming hu hay cc vi khun t d dy rut. Bn cnh , vic t ni kh qun cn cung cp cho cc vi sinh vt mt b mt chng bm dnh v pht trin to thnh cc mng vi khun (bioflim) trn ng ni kh qun lm tng nguy c nhim khun b my h hp. Ngoi ra, vic tch ly cc cht tit b nhim bn t hu hng hoc t ng tiu ha quanh bng chn ni khqunstoiukinchovikhunphttrinvsrrccchttitnyqua bng chn cng gp phn a vi khun vo ng h hp di [47].7TrongccyutnguyccaVPTMcccyutnguycthucvngi bnh v cc yu t nguy c do can thip c trnh by trong bng 1.1.Bng 1.1. Cc yu t nguy c ca VPTM [20, 36]. Cc yu t thuc v ngi bnhCc yu t can thip -Tui 60. -Hi chng suy h hp cp tnh (ARDS).-Bnh phi tc nghn mn tnh (COPD), bnh phi. -Hn m. -Bng, chn thng. -Sau phu thut. -Suy tng. -Tnh trng bnh nng. -Suy gim min dch. -Sc dch ng tiu ha. -Vim xoang. -t li ni kh qun. -t ng thng d dy. -Ni soi ph qun. -D phng lot d dy do stress. -S dng cc thuc c ch min dch (glucocorticoid). -Nm lu. 1.1.4.Chn on vim phi lin quan n th my C nhiu tiu chun chn on VPTM ca cc tc gi khc nhau c xut v cng c nhiu bi bo nghin cu cho thy u, nhc im ca tng tiu chun lm sng khc nhau. Tiu chun theo hng dn ca B Y T [4]. * Tiu chun lm sng - C tn thng mi hoc thm nhim tin trin trn phim X quang phi, km thm t nht 2 trong s cc biu hin sau: + St. + Khc m m. 8+ Bch cu mu ngoi vi tng > 10giga/l hoc gim 1 x 106 CFU / ml. -Chi c bo v : > 1 x 103 CFU / ml. -Dch ra ph qun ph nang : > 1x 104 CFU/ml. -Hoc phn lp vi khun t cy mu hay dch mng phi. BngimnhginhimkhunphicaPugin(CPIS),bngimnh gi nhim khun phi ca Schurink [50, 57] (ph lc 1). Bng im nh gi nhim khun phi ca Pugin (CPIS) da trn 6 du hiu cbn(nhit,bchcu,dchhtphqun,PaO2/FiO2,thmnhimtrnX quangvcykhundch phqun).imnycth nhn gi trt012im. NuimCPIS6thcchnonVPTM[50].Ktqukhisosnhvigii phu bnh l, thy CPIS c nhy trung bnh 77% v c hiu 42% [27]. TbngimnhginhimkhunphiCPISnhnthyviccckt qu vi sinh ngay l iu kh khn do vy m Schurink C.A. v cng s xut tiu chun ch c cc triu chng lm sng v cn lm sng thng thng v bc u cho kt qu ng dng cao. Tuy nhin cc triu chng lm sng qua nghin cu ca Schurink v cng s cho nhy l 83% v c hiu thp 17% khi ly im Schurink >5 [57].Cc du n sinh hc (biomarkers) Procalcitonin (PCT) v Protein C phn ng (CRP) l hai du n sinh hc c p dng nhiu nht trong vic chn on VPTM. -Procalcitonin (PCT): Theo nghin cu ca Duflo F. (2002) trn 96 bnh nhn chothynngPCTtronghuytthanhcnghachnonVPTMtthnso vinngPCTtrongphnang.NghincunycngchrarngvimcPCT trong huyt thanh >3,9 ng/ml cho nhy l 41% v c hiu l 100% [23]. Mt 9nghincukhcccbnhnhnsaukhingngtimvtilplitunhonc VPTMchothyPCTcnhyl100%,chiu75%[52].RamirezP.v cng s theo di nng PCT trong huyt thanh chn on VPTM thy nhy l 78%, c hiu 97% v khi kt hp mc PCT trong huyt thanh > 2,29 ng/ml vi im CPIS > 6 lm tng c hiu ln 100% [51].-ProteinCphnng(CRP):NghinculcaPvoavcngschothy CRP > 9,6 mg/dL c gi tr trong chn on VPTM, vi nhy 87%, c hiu 88% [52].Tuy nhin, trong mt nghin cu trn 47 bnh nhn VPTM da trn kt qu vi sinh cho thy nng CRP cao cho thy c gi tr chn on khng cao [49]. 1.1.5.Tc nhn gy bnh vim phi lin quan n th my Cc tc nhn gy bnh VPTM c th thay i theo m hnh phn b ca cc vi sinh vt ti a phng, thi gian th my, s tip xc vi khng sinh trc , cc bnhmc km,thigiannmvinvthigiannmtikhoaiutrtchccca bnhnhn.CctcnhngybnhthnggpbaogmcctrckhunGramm nh:Pseudomonasaeruginosa,Escherichiacoli,Klebsiellapneumoniae, Enterobacterspp.vAcinetobacterspp.[42].Bncnh,vaitrcacccu khunGramdngtrongvicgyraVPTMngymttngln,cbitl Staphylococcusaureus[42].Virus,nmgyVPTMthngrthimgpnhng ngi c h min dch bnh thng [59]. Cc tc nhn gy VPTM c tng kt t 24nghincuvi1689bnhnhnv2490cctcnhngybnhctrnhby trong bng 1.2 di y. Thigiannmvintrckhikhiphtvimphilmtyutquantrng quyt nh cc tc nhn gy bnh. Vim phi xy ra trong vng 4 ngy u tin nm vinthngdoccvikhunnhycmvikhngsinhnhHaemophilusspp., Streptococcuspneumoniae,vS.aureusnhycmvimethicilin.Trongkhi, vim phi mun (xy ra vo ngy th 5 nm vin hoc lu hn) thng gy ra bi ccvikhunakhng(MDR)baogmP.aeruginosa,Acinetobacterspp.,S. 10aureuskhngvimethicilin. Ccyutnguycnhimvikhunakhngthuc c trnh by bng ph lc 3 [59].Bng 1.2. Cc tc nhn gy VPTM [20, 36]. STTCc tc nhn gy bnhTn s (%) 1Pseudomonas aeruginosa24,4 2Acinetobacter spp.7,9 3Stenotrophomonas maltophilia1,7 4Enterobacteriaceae*14,1 5Haemophilus spp.9,8 6Staphylococcus aureus+20,4 7Streptococcus spp.8,0 8T cu khng sinh men coagulase 1,4 9Neisseria spp.2,6 10Cc vi khun k kh0,9 11Nm0,9 12Cc tc nhn gy bnh khc (< 1% mi loi)++3,8 *Sphnbcth:Klebsiellaspp.15,6%,Escherichiacoli24,1%,Proteusspp. 22,3%,Enterobacterspp.18,8%,Serratiaspp.12,1%,Citrobacterspp.5,0%, Hafnia alvei 2,1%. +Sphnbcth:S.aureuskhngmethicillin55,7%,S.aureusnhyvi methicilin 44,3%. ++ Bao gm: Corynebacterium spp., Moraxella spp., v Enterococcus spp. CcbnhmckmcngcthnhhngntcnhngybnhVPTM. VPTMccbnhnhnCOPDthngcnguyccaodoccvikhunnh: H.influenzae,MoraxellacatarrhalishocS.pneumoniae;trongkhinhngbnh nhn b cc bnh l thn kinh v chn thng thng tng nguy c nhim S.aureus [20].MtnghincubnhnhnVPTMsauiphuthuttim(majorheart 11surgery)chothyEnterobacteriaceaechimtlcaonht(32,8%),tiplP. aeruginosa (28.6%) v S. aureus (27,1%) (65,8% trong s l MRSA) [34]. VPTM c th do nhiu tc nhn gy ra. Mt nghin cu ch ra rng c hn mttcnhngybnhctmthytrongkhong3070%cctrnghp VPTM [36]. Trong khi , nghin cu ca Hortal J. v cng s bnh nhn sau i phu thut tim cho thy VPTM do a vi khun gy ra chim 13,5% [34]. Trong hai nghin cu khc c thc hin n , 12,3% v 16,3% cc trng hp VPTM l do a vi khun [36]. 1.2.TNH HNH KHNG THUC CA CC VI KHUN HIN NAYTheo bo co ca mng li an ton chm sc sc khe quc gia ca M (The NationalHealthcareSafetyNetwork(NHSN))nm20092010,tlkhng khng sinh ca cc vi khun gy VPTM c s tng nh so vi nm 2007 - 2008.T l khng carbapenem ca A. baumannii nm 2009 - 2010 l 61,2%, cao hn so vi nm2007-2008(56,7%).TlkhngvancomycincaEnterococcusfaecium tng t 82,4% (nm 2007 - 2008) n 82,6% (nm 2009 - 2010). Trong khi , t l khng oxacilin ca S. aureus nm 2009 -2010 l 48,4% gim nh so vi nm 2007-2008(51,9%).30,2%ccchngP.aeruginosaphnlpcnm2009-2010 khngvicarbapenemvviEnterobacterspp.consnychl3,6%.Tl khngcefepime,cefotaxime,ceftazidime,ceftriaxonecaEnterobacterspp.nm 2009-2010 l 30,1% [58].Ti Chu , trong mt nghin cu c tin hnh ti 73 bnh vin nm 2008 -2009, Chung D.R. v cng s ch ra rng cc vi khun phn lp c ch yu t bnh nhn vim phi bnh vin v VPTM l Acinetobacter spp., P. aeruginosa, S. aureus,vK.pneumoniae.TlkhngimipenemcaAcinetobacterspp.vP. aeruginosatngngl67,3%v27,2%,tlakhngthucl82%v42,8. Trongkhi,tlakhngthuccaK.pneumoniael44,7%vtlkhng oxacilin ca S. aureus l 82,1% [22].12Ti Vit Nam, t l khng khng sinh ca cc vi khun cng l mt vn rt c quan tm. Theo bo co ca hot ng Theo di s khng khng sinh ca ccvikhungybnhthnggpVitNamtnm2004nnm2006,s khng thuc ca cc vi khun ngy mt tng. Tnh chung cho c nc, nm 2004, t l khng imipenem caP.aeruginosa l 15,5%, nm2005l18,4%(cbit bnh vin Nhi trung ng, t l khng imipenem ca vi khun ny l 52,3%, v n 6 thng u nm 2006 l 20,7%. Trong khi , 10,0% Acinetobacter spp. khng imipenemnm2004vnnm2005,tlnyl18,3%,ringbnhvinBch Mai,42,2%ccchngvikhunnykhngimipemem.TlS.aureuskhng oxacilinkhcao,nm2004l38,1%,nm2005l43,7%,cbitbnhvin TrungngHul64,4%.VicctrckhunngrutnhE.coli,Klebsiella spp.tlkhng cefotaximnm2005lnltl43,7%v56,9%[10-12].Mt nghin cu khc c thc hin ti bnh vin Bch Mai t thng 9/2009 n thng 8/2011ccbnhnhnVPTMchothyA.baumanniivP.aeruginosakhngli nhiuloikhngsinhthngdnghinnayvitlkhcao,trongA. baumannii c t l khng vi ceftazidime, ciprofloxacin n 75%, P. aeruginosa khngcaonhtviampicillin/sulbactamvamikacin(62,5%).Ngaycvinhm khng sinh ph rng, hot lc mnh nh imipenem, meropenem, t l khng ca A. baumannii cng ln n hn 50% [8]. 1.3.IU TR VIM PHI LIN QUAN N TH MY1.3.1.Nguyn tc iu tr vim phi lin quan n th my Hin nay, nhim khun do cc tc nhn gy bnh a khng thuc ngy mt gia tng,cbitltikhoaiutrtchcc.Trongkhi,mttrongnhngnguyn nhnchnh chnhkhngsinhcckhoaiu trtch cclnhimkhunh hp mc phi ti bnh vin. Cc bc s, cc nh lm sng lun phi i mt vi cc vn hoc l iu tr qu mc hoc l iu tr khng nhng bnh nhn tht s cn c iu tr [19]. Theo KollefM.H. iu tr VPTM cn m bo c hai mc tiu: ti u ha kt qu iu tr cho bnh nhn ng thi hn ch s xut hin ca 13ccchngkhngthuc[39].MtsnguyntcchungtrongiutrVPTM[39, 59]: -Cy bnh phm ca ng h hp di cn c thc hin tt c cc bnh nhnnghing VPTM trc khi iu tr khng sinh, tuy nhin, khng nn tr hon iu tr khng sinh ban u cho bnh nhn cho ti khi c kt qu cy. -iu tr khng sinh ban u sm, thch hp, ph rng, liu y ti u ha hiu qu ca khng sinh ngay khi nghi ng VPTM. -Phckhngsinhbanuphiphhpvitcnhngybnh:lachn khng sinh ban u phi da vo cc kin thc vi sinh ti a phng v cc yu t nguy c nhim vi khun a khng thuc ca bnh nhn. -Chuyn sang liu php khng sinh thu hp hoc xung thang khi c kt qu vi sinh v khi bnh nhn c p ng trn lm sng. -Thi gian iu tr khng sinh nn ngn nht c th.1.3.2.La chn khng sinh ban u theo kinh nghim 1.3.2.1. ngha ca phc khng sinh ban u iu tr khng sinh banuthchhplmttrongnhngvnquantrng i vi vic chm sc bnh nhn VPTM [32].Theo Leroy O. v cng s, iu tr khng sinh ban u c coi l thch hp khi khong thi gian t lc c chn on nghi ng VPTM n khi khng sinh c sdngtrongvng24givttccctcnhngybnhphnlpcnhy invitro vi t nht mt khng sinh c trong phc [43].Vic iu tr khng sinh ban u sm, thch hp khng nhng c lin quan n vic gim t l t vong m cn gp phn lm gim chi ph, gim thi gian nm vin ca bnh nhn [39, 59]. Hu ht cc nghin cu u ch ra rng iu tr khng sinh banukhngyhocchmtrtrongvicbtuiutrkhngsinhtheo kinh nghim c lin quan n vic tng t l t vong bnh nhn VPTM [22, 35, 43, 44]. Trong khi , vic thay i liu php khng sinh khi c kt qu cy c th cng khng lm gim nguy c t vong nhng bnh nhn iu tr ban u khng 14thch hp [44]. Ngoi ra, theo Kollef MH., mt trong nhng hu qu khc ca iu tr ban u khng y l tng tnh khng khng sinh ca vi khun. Cc tc nhn gy bnh ph bin nht lin quan n vic iu tr khng y bnh nhn VPTM l P. aeruginosa (trn 35%), tip l S. aereus v Acinetobacter spp. [40].1.3.2.2. La chn khng sinh trong phc khng sinh ban uVic la chnkhngsinhban unndavomhnhvtnhkhngthuc ca cc tc nhn gy bnh ti a phng, cc yu t c th trn bnh nhn nh l mcnngcabnh,thigiannmvin,csdngkhngsinhtrchay khngcngnhphicncvochiph,tnhsnccacckhngsinhtia phng [35, 36].Trcht,viclachnkhngsinhbanunndavomhnhvtnh khng thuc ca cc tc nhn gy bnh ti a phng bi v cc tc nhn gy bnh c th khc nhau gia cc bnh vin, gia cc khoa iu tr tch cc v c th thay i theo thi gian ngay trong mt khoa iu tr tch cc [46, 59].Cc yu t thuc v ngi bnh cng c vai tr quan trng trong vic la chn khng sinh ban u. Theo mt hng dn iu tr ca Canada (2008), khi bnh nhn cccbiuhinlmsng(hhuytp,rilonchcnngcccquan,rilon ingii)thnggintnhtrngVPTMnngvthngdoP.aeruginosa, MRSA,Acinetobacterspp.[54].Thigiannmvincnglmtcncla chnkhngsinhbanu.Vimphixyratrong4ngyutinnmvinv khng c cc yu t nguy c nhim cc tc nhn a khng thuc thng do cc vi khun nhy cm vi khng sinh nhHaemophilus spp., Streptococcus pneumoniae, vS.aureusnhycmvimethicillin.Trongkhi,VPTMmunthnggyra bi cc vi khun a khng (MDR) nh P. aeruginosa, Acinetobacter spp., S. aureus khng vi methicillin [59]. Theohng dnca hip hi lngngcHoaK(2005),phckhngsinh ban u cn c ph rng bao ph c cc tc nhn gy bnh. Khi c nghi ng nhim cc tc nhn a khng thuc nn s dng liu php phi hp gim thiu 15nguyciutrbanukhngphhp.CctrnghpnghingnhimP. aeruginosa,nnlachnmt-lactamkthpvimtquinolonchng Pseudomonas hoc aminoglycosid [59]. Ngoi vic la chn ng khng sinh, ti u ha liu php khng sinh ban u vic s dng ng liu, ng ng dng cng nh da vo cc c tnh dc ng hc, dc lc hc, c tnh ca khng sinh cn c quan tm [59].Cchngdnlachnkhngsinhbanu,liudngcakhngsinhtheo hng dn ca B Y T, theo hip hi lng ngc Hoa K (2005) c trnh by ph lc 3 [4, 59]. 1.3.3.La chn khng sinh theo cn nguyn vi khun hc Vicsdngliuphpkhngsinhqumcsdnntngccbinchng lin quan n iu tr, tng chi ph khng cn thit v gp phn lm tng tnh khng thuc ca vi khun . V vy, khi c kt qu cy cc bnh phm ng h hp hoc ktqucymu,iutrnnctptrunghocthuhpdatrntcnhngy bnh xc nh c v tnh nhy cm ca n vi khng sinh [59].-iutrStaphylococcusaureuskhngmethicilin(MRSA):MRSAlmt trongnhngtcnhnchnhgyVPTM.CctrnghpVPTMdotcuvng khngmethicilinthngctltvongcaohnsoviccchngnhycmvi methicilin [17]. Vancomycin vn l mt la chn truyn thng iu tr VPTM v ccnhimtrngnghimtrngkhcdoMRSA.Linezolidlmtkhngsinhmi hin nay iu tr MRSA [59]. Tuy nhin, trong mt phn tch meta, Walkey A.J. vcngschngminhrnglinezolidkhngvttrihnglycopeptidvkt qu trn lm sng( RR = 1,04; 95% CI = 0,97 - 1,11; P = 0,28), kt qu vi sinh (RR = 1,13; 95% CI = 0,97 - 1,31; P = 0,12), v t l t vong (RR = 0,91; 95% CI= 0,69 -1,18;P=0,47).Cctcgicanghincunycngkhuyncorngvicla chn linezolid hay glycopeptid nn da vo tnh nhy cm ca vi khun, chi ph v tnhsnctiaphng[60].TheohngdncahiphilngngcHoaK 16(2005),linezolidcthlmtlachnthaythchovancomycincbitl nhng bnh nhn suy thn hoc ang dng cc thuc c vi thn [59]. -iu tr P. aeruginosa: P. aeruginosa c kh nng pht trin khng khng sinhnhanhchng.TheohngdncahiphilngngcHoaK(2005),liu php kt hp nn c s dng vi cc trng hp vim phi do P. aerruginosa v iutrkthpcthkhngnhtthitphingnchnckhng,nhngkt hp iu tr c nhiu kh nng trnh c iu tr khng ph hp v khng hiu qu cho bnh nhn [59]. Liu php phi hp thng c s dng theo hng dn ca BYTlkthpgia-lactamchngPseudomonas(cefepim,ceftazidim)vi aminoglycosid hoc carbapenem vi aminoglycosid [4].-iutrAcinetobacterspp.:HngdncahiphilngngcHoaK (2005) khuyn co rng carbapenem l khng sinh c la chn iu tr cc chng Acinetobacter spp., tuy nhin khi cc chng ny khng carbapenem, colistin cthlmtiutrthayth[59].Trongmtphntchmetavtngquanh thng, Florescu D.F. v cng s cng kt lun colistin l an ton v hiu qu iu tr VPTM [28]. Cc khng sinh thay th khc l sulbactam v polymyxin [59]. -Cc vi khun ng rut (Enterobacteriaceae) sinh ESBL (-lactamase hot phrng):VicccvikhunngruttitmenESBLlmtpngbini caccvikhunnyivikhngsinhcephalosporinthh3dokhiccvi khun ng rut sinh ESBL c phn lp th khng nn s dng n tr liu mt cephalosporin th h 3 [21]. Mt khc, cc vi khun ny cng c kh nng khng viaminoglycosidvfluoroquinolon,nnlichcavickthplkhngchc chn.TheohngdncahiphilngngcHoaK,carbapenemnncs dng khi cc vi khun ng rut sinh ESBL c phn lp [59]. HngdnlachnkhngsinhkhicktquvikhunhccaBYT c trnh by trong ph lc 2 [4]. 17CHNG 2. I TNG V PHNG PHP NGHIN CU 2.1.I TNG NGHIN CU i tng nghin cu l bnh n ca bnh nhn vim phi lin quan n th my c iu tr ti khoa Hi sc cp cu bnh vin a khoa c Giang t thng 1/2012 n thng 12/2012. 2.1.1.Tiu chun la chn-Tui 16. -c chn on vim phi sau ch nh th my trn 48 gi. 2.2.PHNG PHP NGHIN CU 2.2.1.Thit k nghin cu Phng php m t hi cu ct ngang. 2.2.2.Phng php ly mu Phng php ly mu: ly ton b bnh n ca khoa Hi sc cp cu bnh vinakhoacGiangtrongthigiantthng1/2012nthng12/2012tha mn tiu chun la chn v tiu chun loi tr. Tng s bnh n c la chn l 46 bnh n. 2.2.3.Phng php thu thp thng tin Thng tin thu thp t bnh n c ghi li trong phiu thu thp thng tin bnh n (ph lc 4). 2.2.4.Cc ch tiu nghin cu 2.2.4.1. c im ca bnh nhn * Cc c im chung: -Tui, gii. -Chn on lc nhp khoa. -Thi gian nm ti khoa Hi sc cp cu. 18-Thi gian th my. -Thi gian dng khng sinh. -Kt qu iu tr. * Cc yu t nguy c lin quan n VPTM: -Tui 60. -COPD. -t li ng ni kh qun. -ang t ng thng d dy. -D phng lot d dy do stress. 2.2.4.2. Cc tc nhn gy bnh v tnh khng khng sinh ca cc vi khun gy bnh -Thng k cc tc nhn gy VPTM. -Thng k tnh trng khng khng sinh ca cc vi khun gy VPTM da trn kt qu khng sinh . 2.2.4.3. Kho st tnh hnh s dng khng sinh trn bnh nhn VPTM -T l cc khng sinh c s dng trn bnh nhn VPTM. -Slngccphc1khngsinh,phcphihp2hoc3khngsinh c ch nh trn bnh nhn VPTM. -Cc la chn khng sinh theo thi im chn on VPTM. -Cc la chn khng sinh trong phc ban u iu tr VPTM. 2.2.5.Mt s khi nim trong nghin cu -VPTMsm:khithigiannmvinnkhibnhnhncchnon VPTM trong vng 4 ngy. -VPTMmun:khithigiannmvinnkhibnhnhncchnon VPTM 5 ngy. 19-Phc trc khi c chn on VPTM: phc khng sinh c s dng t khi bnh nhn nhp khoa n ngay trc khi chn on VPTM. -Phcbanu:phckhngsinhcsdngutinkhicchn on VPTM. -Phc thay th: phc khng sinh c s dng sau phc ban u n khi bnh nhn ri khoa Hi sc cp cu. -PhcbanukhicchnonVPTMccoilphhpviktqu khng sinh khi cc vi khun phn lp c nhy cm vi t nht mt thuc trong phc . 2.3.PHNG PHP X L S LIU Sliucxltheoccthuttonthngkyhc,sdngphnmm SPSS 19. * Kt qu c m t theo: -Gi tr trung bnh, lch chun: vi cc bin nh lng phn phi chun. -Gi tr trung v - cc gi tr gii hn (cao nht thp nht): vi cc bin nh lng phn phi khng chun. -T l: vi cc bin phn loi. 20CHNG 3. KT QU 3.1.C IM CA BNH NHN3.1.1.c im chung ca bnh nhn nghin cu Chngtilachnc46bnhncabnhnhnVPTMiutrtikhoa Hi sc cp cu bnh vin a khoa c Giang t thng 1/2012 n thng 12/2012 avonghincu.cimchungcanhmbnhnhnnghincuctrnh by bng 3.1. Bng 3.1. Cc c im chung ca bnh nhn VPTM Thng sS bnh nhnT l (%) Gii tnh(n = 46) Nam 2963,0 N 1737,0 Tui (n= 46)76 11 (nm) Nhm tui (n= 46) 40 n 59 510,9 60 n 79 2350,0 80 1839,1 Chn on lc nhp khoa (n= 46) Bnh l h TKTW 2350,0 Bnh l h h hp 1634,8 Bnh l h tun hon 36,5 Bnh l h tit niu12,2 Bnh l h tiu ha 12,2 Bnh l khc 24,3 Thi gian nm ti khoa Hi sc cp cu (n= 46)15,4 8,3 (ngy) Thi gian th my (n= 46)13,8 7,3 (ngy) Thi gian dng khng sinh (n= 46)13,3 7,2 (ngy) 21Nhn xt:T l bnh nhn nam l 63,0% cao hn t l bnh nhn n (37,0%).Tui trung bnh ca cc bnh nhn l 76 11. Nhm tui chim t l cao nht l 60-79 (50,0%), sau n nhm tui 80 (39,1%) v nhm tui 40-59 (10,9%). VPTMthnggpnhtnhngbnhnhncbnhlTKTW(50,0%),tip theolbnhlhhhp(34,8%),cnlilbnhnhncbnhlhtunhon (6,5%), h tit niu (2,2%), h tiu ha (2,2%) v cc bnh l khc (4,3%). Thi gian iu tr ti khoa Hi sc cp cu ca bnh nhn VPTM trung bnh l 15,48,3ngy.Trongkhi,thigianthmytrungbnhl13,87,3vthi gian dng khng sinh trung bnh l 13,3 7,2. 3.1.2.Kt qu iu tr Kt qu iu tr ca bnh nhn c xc nh da trn kt lun ca bc s tng ktbnh n: khi,/gim,khngthayi,nnghn,tvongtrnhbynhhnh 3.1 bn di. Hnh 3.1. Kt qu iu tr ca bnh nhn VPTM Nhn xt: T l bnh nhn c kt qu iu tr /gim v nng hn bng nhau (41,3%). Nghin cu ca chng ti khng ghi nhn c BN no t vong hay khi bnh. 17.441.341.3, gimKhng thay iNng hn223.1.3.Cc yu t nguy c ca VPTM Cc yu t nguy c mc VPTM ca bnh nhn c trnh by nh bng 3.2. Bng 3.2. Cc yu t nguy c mc VPTM STTCc yu t nguy cS bnh nhn (n= 46)T l (%)1Tui 60 4189,1 2COPD 1430,4 3t li ni kh qun1123,9 4ang t ng thng d dy 46100,0 5D phng lot d dy do stress2860,9 Nhnxt: Trongs 46 bnhnhncavonghincu, 41bnhnhn 60 tui (89,1%), 46 bnh nhn t ng thng d dy (100,0%), t l bnh nhn mc COPDl30,4%,tltlinikhqunl23,9%vangsdngthucd phng lot d dy do stress c ghi nhn 28 bnh nhn (60,9%). 3.1.4.Phn loi bnh nhn theo VPTM sm v VPTM mun T l VPTM sm v VPTM mun c trnh by trong bng 3.3. Bng 3.3. T l VPTM sm v VPTM mun VPTMS bnh nhnT l (%) VPTM sm1328,3 VPTM mun3371,7 Tng 46100,0 Nhnxt:TlVPTMmuntrongnghincucachngtil71,7%cao hn t l VPTM sm (28,3%).3.2.CC TC NHN GY BNH VPTM 3.2.1.c im v xt nghim vi sinh v vi sinh vt gy bnh c im v xt nghim vi sinh v cc tc nhn gy bnh phn lp c trn bnh nhn VPTM iu tr ti khoa Hi sc cp cu - bnh vin a khoa c Giang c trnh by trong bng 3.4.23Bng 3.4. c im v xt nghim vi sinh v vi sinh vt gy bnh Thng sKt quT l (%) Bnh phm (n= 52)m ni kh qun52100 Kt qu xt nghim vi sinh (n = 52) m tnh 35,8 Dng tnh 4994,2 Cc tc nhn gy bnh phn lp c trn bnh nhn(n= 55) Gram m 5192,7 Acinetobacter baumannii2036,4 Klebsiella pneumoniae916,4 Escherichia coli814,5 Pseudomonas aeruginosa59,1 Pseudomonas sp.23,6 Proteus mirabilis11,8 Enterobacter aerogenes11,8 Citrobacter freundii23,6 Stenotrophomonas maltophilia11,8 Chryseobacterium meningosepticum 23,6 Gram dng 23,6 Staphylococcus aureus23,6 Nm 23,6 Candida sp. 23,6 S tc nhn gy bnh trn bnh nhn VPTM (n= 46) 1 tc nhn gy bnh 3780,4 2 tc nhn gy bnh 919,6 Nhn xt: 100% bnh nhn c lm xt nghim vi sinh. Tng s xt nghim visinhl52.Ccbnhphmclmxtnghimulmnikhqun (100,0%). Hu ht xt nghim c kt qu dng tnh (94,2%), ch c 3 trng hp m tnh (5,8%). 24T 49 bnh phm xt nghim dng tnh phn lp c 55 chng, trong c 51chngvikhunGramm(92,7%),2chngvikhunGramdng(3,6%)v2 chng nm (3,6%). Cc chng vi khun thng gp u l vi khun Gram m, gm c A. baumannii (36,4%), K. pneumoniae (16,4%), E. coli (14,5%) v P. aeruginosa (9,1%). Cc chng Gram dng phn lp c u l S. aureus (3,6%). Trong 46 bnh nhn c a vo nghin cu, 37 bnh nhn (80,4%) phn lp c1tcnhngybnh,cnli9bnhnhn(19,6%)phnlpc2tcnhn gy bnh. 3.2.2.Phn loi vi khun theo VPTM sm v VPTM mun T l cc tc nhn gy bnh theo VPTM sm v mun c trnh by trong hnh 3.2. 01020304050VPTM sm (N=13) 46.2 23.1 7.7 0 7.7 7.7 7.7VPTM mun (N=42) 33.3 14.3 16.7 11.9 2.4 2.4 2.4A. baumanniiK. pneumoniaeE. coli P. aeruginosa S. aureusPseudomonas sp.Candida sp.Hnh 3.2. T l cc tc nhn gy bnh theo VPTM sm v mun Nhn xt: Vi khun gy VPTM mun ph bin nht lA. baumannii (30,4%), ng th hai l E. coli (15,2%), tip l K. pneumoniae (13,0%) v P. aeruginosa (10,9%). Trong khi , VPTM sm ch yu do A. baumannii (13,0%), tip l K. pneumoniae(6,5%),E.colivPseudomonassp.(miloi2,2%).Haichng T l (%) 25S.aureusphnlpc,1chng(2,2%)gyVPTMsm,1chng(2,2%)gy VPTM mun. Cc vi khun khc phn lp c u gy VPTM mun. 3.2.3.Tnh khng khng sinh ca mt s vi khun gy bnh thng gp CcvikhunthnggpphnlpctrnbnhnhnVPTMbaogm:A. baumannii, K. pneumoniae, E. coli, P. aeruginosa. Tnh khng khng sinh ca cc vi khun ny da theo kt qu khng sinh c trnh by trong hnh 3.3 v hnh 3.4. 0102030405060708090100A. baumannii 90 94.7 80 100 80 90 88.9 64.7 88.9 88.2P. aeruginosa 60 100 60 66.7 25 * 80 100 100 100Ceftazidim Ceftriaxon Imipenem MeropenemPiperacilin/ tazobactamAmpicilin/ sulbactamCIP LEV Gentamicin Tobramycin Ch thch: *: khng c lm khng sinh , CIP: levofloxacin, LEV: levofloxacin. Hnh 3.3. T l khng khng sinh ca A. baumannii v P. aeruginosa Nhn xt: A. baumannii v P. aeruginosa c t l khng cao vi nhiu loi khngsinh.TlkhngcaA.baumanniiviceftazidiml90,0%,imipenem T l (%) 26(80,0%),meropenem(100,0%),piperacilin/tazobactam(80,0%),ciprofloxacin (88,9%)caohnsovitlkhngcaP.aeruginosavicckhngsinhny ((ceftazidim(60,0%),imipenem(60,0%),meropenem(66,7%),ciprofloxacin (80,0%),piperacilin/tazobactam(25,0%).Viccaminoglycosid,tlkhng caA.baumannii((gentamicin(88,9%),tobramycin(88,2%))thphnsoviP. aeruginosa ((gentamicin (100,0%), tobramycin (100,0%)). 0102030405060708090100K. pneumoniae 100 71.4 100 62.5 50 25 0 87.5 28.6 37.5 42.9 62.5 44.4E. coli 100 100 100 100 100 42.9 0 62.5 0 50 85.7 83.3 50Ampicilin Cefuroxim Cefoxitin Ceftriaxon Cefepim Imipenem Ertapenem AMCPiperacilin/tazobactamTicarcilin/ acid clavulanicGEN TOB AmikacinCh thch: GEN: gentamicin, TOB: tobramycin, AMC: amoxicillin/acid clavulanic Hnh 3.4. T l khng khng sinh ca K. pneumoniae v E. coli Nhnxt:TlkhngcaK.pneumoniaevE.coliviampicilin, cefoxitinul100,0%.Chaivikhunnykhngthpvi piperacilin/tazobactam:K.pneumoniae(28,6%),E.coli(0%).100%ccchngE. colikhngvicefuroxim,cefepim.Trongkhi,tlkhngcaK. pneumoniaevicefuroximl71,4%,cefepim(50,0%).TlkhngcaK. peumoniaevigentamicin(42,9%),tobramycin(62,5%),amikacin(44,4%)thp hn so vi E. coli (gentamicin (85,7%), tobramycin (83,3%), amikacin (50,0%).T l (%) 273.3.KHO ST TNH HNH S DNG KHNG SINH TRONG IU TR VPTM3.3.1.Cc khng sinh c s dng Cc khng sinh c s dng trn bnh nhn VPTM c trnh by nh bng 3.5. Bng 3.5. Cc khng sinh c s dng trn bnh nhn VPTM Khng sinhS ln s dng T l (%) - lactam PenicilinAmoxicilin/acid clavulanic10,7 Piperacilin/tazobactam149,9 C2GCefuroxim10,7 C3GCeftazidim64,3 Ceftriaxon3122,0 Cefotaxim21,4 Cefoperazon32,1 Cefoperazon/sulbactam85,7 C4GCefpirom32,1 CarbapenemImipenem53,5 Meropenem10,7 QuinolonCiprofloxacin1812,8 Levofloxacin3021,3 Pefloxacin10,7 AminoglycosidAmikacin64,3 MacrolidAzithromycin32,1 PeptidColistin21,4 ImidazolMetronidazol42,8 Sulfonamid Sulfamethoxazol/trimethoprim21,4 Tng 141100,0 28Nhn xt: Nhm - lactam c s dng nhiu nht, sau l fluoroquinolon vaminogycosid.Cephalosporinthh3vpenicilinchimtlcaonhttrong nhm-lactam.Ceftriaxonlcephalosporinthh3cdngnhiunht (22,0%),thhailcefoperazon/sulbactam(5,7%)vthbalceftazidim(4,3%). Trong cc penicilin, piperacilin/tazobactam c ch nh nhiu nht (9,9%). Trong khi,levofloxacinlfluoroquinolonphbinnht(21,3%).Ccaminogycosid c dng u l amikacin (4,3%). 3.3.2.Cc liu php khng sinh c s dng3.3.2.1. Cc phc khng sinh trn bnh nhn VPTM Cc phc khng sinh trn bnh nhn VPTM c trnh by trong hnh 3.5.46.347.85.9Phc n cPhc phi hp 2khng sinhPhc phi hp 3khng sinh Hnh 3.5. T l cc phc khng sinh trn bnh nhn VPTM Nhnxt:Nhnchung,phcphihp2khngsinhvphcnc cchnhnhiunhtvkhtngngchimtltngngl47,8%v 46,3%. Trong khi , phc phi hp 3 khng sinh c dng t nht (6,0%). 3.3.2.2. Phc 1 khng sinh Cc phc 1 khng sinh s dng trn bnh nhn VPTM c trnh by trong bng 3.6. 29Bng 3.6. Cc phc 1 khng sinh c s dng Nhm khng sinhS ln s dngT l (%) Penicilin914,5 Cephalosporin th h 211,6 Cephalosporin th h 33861,3 Carbapenem34,8 Fluoroquinolon914,5 Sulfonamid11,6 Peptid11,6 Tng62100,0 Nhn xt: Cc phc 1 khng sinh c dng u l thuc nhm - lactam v quinolon. Trong , cephalosporin th h 3 l phbin nht (61,3%), sau l penicillin v fluoroquinolon (mi loi 14,5%).3.3.2.3. Cc phc phi hp 2 khng sinh Trong nghin cu ca chng ti c 64 phc phi hp 2 khng sinh c th hin nh bng 3.7. 30Bng 3.7. Cc phc phi hp 2 khng sinh c s dng STTPhc S ln s dngT l (%) 1Penicilin + FQ914,1 2Penicilin + Aminoglycosid11,6 3Penicilin + Macrolid11,6 4C2G +FQ11,6 5C3G + FQ3757,8 6C3G + Aminoglycosid34,7 7C3G + Macrolid11,6 8C3G + Metronidazol11,6 9C3G + C3G 11,6 10C4G + FQ11,6 11C4G + Aminoglycosid11,6 12C4G + Penicilin11,6 13FQ +Carbapenem34.7 14FQ +Sulfonamid11,6 15FQ +Peptid11,6 16Sulfonamid + Macrolid11,6 Tng64100,0 Nhn xt: Phc 2 khng sinh c s dng nhiu nht l cephalosporin th h3+fluoroquinolon(57,8%),tipnsaulphihpgiapenicilin+ fluoroquinolon(14,1%)vphihpgiafluoroquinolon+carbapenem, cephalosporinthh3+aminoglycosid(miloichim4,7%).C1trnghp phihp2khngsinhcephalosporinthh3v1trnghpphihp cephalosporin th h 4 vi penicilin. 3.3.2.4. Phc phi hp 3 khng sinh Phc phi hp 3 khng sinh trn bnh nhn VPTM c trnh by trong bng 3.8. 31Bng 3.8. Cc phc phi hp 3 khng sinh c s dng Phc S ln s dng T l (%) Ceftriaxon + piperacilin/tazobactam + ciprofloxacin112,5 Ceftriaxon + levofloxacin + amikacin112,5 Ceftriaxon + pefloxacin + metronidazol112,5 Cefoperazon + ciprofloxacin + metronidazol112,5 Cefpirom + imipenem/ cilastatin + levofloxacin112,5 Piperacilin/tazobactam + imipenem/ cilastatin + levofloxacin112,5 Piperacilin/tazobactam + levofloxacin + azithromycin112,5 Piperacilin/tazobactam + levofloxacin + metronidazol112,5 Tng8100,0 Nhn xt: Nhn chung c 8 phi hp 3 khng sinh c ch nh v mi phi hp c s dng 1 ln chim 12,5%. C 8 phc u c s dng fluoroquinolon, theosaulcccephalosporinthh3,cephalosporinthh4(4phc)v piperacilin/tazobactam trong 3 phc . 3.3.3.La chn khng sinh theo thi im chn on VPTM 3.3.3.1. Cc loi phc khng sinh theo thi im chn on VPTM Phn loi cc phc khng sinh theo thi im chn on VPTM c trnh by trong bng 3.9. Bng 3.9. T l (%)cc phc khng sinh theo thi im chn on VPTM Loi phc P trc khi chn on VPTM (n = 46) P ban u khi c chn on VPTM (n = 46) P thay th sau khi c chn on VPTM (n = 46) Phc 1KS31 (67,4)14 (30,4)18 (39,1) Phc 2 KS18 (39,1)30 (65,2)21 (45,7) Phc 3 KS4 (8,7)2 (4,3)3 (6,5) 32Nhnxt:TrongphctrckhichnonVPTM,phc1khngsinh csdngnhiunht(67,4%),tiptheolphc2khngsinh(39,1%)v phc3khngsinh(8,7%).Ngcli,phc2khngsinhlphbinnht trong phc ban u (65,2%), tip l phc 1 khng sinh (30,4%) v phc 3 khng sinh (4,3%). Trong phc thay th, phc t c ch nh nht l phc 3khngsinh(6,5%)vphcdngnhiunhtlphc2khngsinh (45,7%).3.3.3.2. Khng sinh trong cc phc thng gp nht theo thi im chn on VPTM Cc khng sinh trong nhng phc thng gp nht theo thi im chn on VPTM c trnh by trong bng 3.10. Bng 3.10. T l (%) cc phc khng sinh thng gp nht theo thi im chn on VPTM Khng sinhP trc khi chn on VPTMP ban u khi c chn on VPTMP thay th sau khi c chn on VPTMPhc 1 khng sinh (n = 46) Ceftriaxon22 (47,8)3 (6,5)1 (2,2) Piperacilin/tazobactam0 (0,0)1 (2,2)8 (17,4) Cefoperazon/sulbactam3 (6,5)4 (8,7)0 (0,0) Ciprofloxacin0 (0,0)1 (2,2)3 (6,5) Phc 2 khng sinh (n = 46) Ceftriaxon + ciprofloxacin3 (6,5)7 (15,2)1 (2,2) Ceftriaxon + levofloxacin4 (8,7)10 (21,7)2 (4,3) Piperacilin/tazobactam + ciprofloxacin 0 (0,0)1 (2,2)2 (4,3) Piperacilin/tazobactam + levofloxacin 0 (0,0)0 (0,0)5 (10,9) 33Nhnxt:Phc1khngsinhphbinthiimtrckhichnon VPTMlceftriaxon(47,8%),khicchnonVPTMlcefoperazon/sulbactam (8,7%)vtrongphcthaythlpiperacilin/tazobactam(17,4%).Phc2 khng sinh ch yu thi im trc khi chn on v khi c chn on VPTM l phi hp gia ceftriaxon + levofloxacin (tng ng l 8,7%; 21,7%), trong khi phcthayth,piperacilin/tazobactam+levofloxacinlkthpphbinnht (10,9%).3.3.4.La chn khng sinh ban u trong iu tr VPTM 3.3.4.1.Cc phc khng sinh trong phc ban u iu tr VPTM sm v mun Ccphckhngsinhbanukhichnonvimphilinquannth my trong iu tr VTPM sm v VPTM mun c trnh by nh bng 3.11. Bng 3.11. T l cc phc ban u trong iu tr VPTM sm v mun Phc ban uVPTM sm (n= 46) VPTM mun (n= 46) Phc 1 khng sinh4 (8,7)10 (21,7) C3G3 (6,5)6 (13,0) Carbapenem1 (2,2)0 Khc04 (8,7)* Phc 2 khng sinh 8 (17,4)22 (47,8) C3G + FQ8 (17,4)15 (32,6) Khc 07 (15,2)+ Phc 3 khng sinh1 (2,2)1 (2,2) C3G + FQ + Imidazol1 (2,2)0 Penicilin + FQ + Macrolid01 (2,2) Ch thch:* bao gm: penicilin (2,2%), fluoroquinolon (6,5%). + bao gm: C3G + aminoglycosid (4,3%), penicilin + fluoroquinolon, cephalosporin th h 2 + fluoroquinolon, cephalosporin th h 4 + fluoroquinolon, carbapenem + fluoroquinolon, fluoroquinolon + peptid (mi loi 2,2%). 34Nhnxt:PhciutrVPTMsmtptrungchyuvo2phc: cephalosporin th h 3 + fluoroquinolon (17,4%) v cephalosporin th h 3 (6,5%). Trongkhi,ngoiphccephalosporinthh3+fluoroquinolon(32,6%), cephalosporinthh3(13,0%),iutrVPTMmuncnsdngphbincc phckhc:phcfluoroquinolon(6,5%),cephalosporinthh3+ aminoglycosid (4,3%). 3.3.4.2. nh gi la chn khng sinh ban u trong iu tr VPTM da trn kt qu khng sinh Phc khng sinh ban u c coi l ph hp khi cc vi khun phn lp c nhy cm vi t nht mt thuc trong phc c ban u c s dng. T l ph hp ca cc phc khng sinh ban u c trnh by theo bng 3.12. Bng 3.12. T l ph hp ca cc phc khng sinh ban u theo kt qu khng sinh Phc ban uS phc (n= 46)T l (%) Phc ban u ph hp1532,6 Phc ban u khng ph hp1941,3 Khng xc nh c1226,1 Tng46100,0 Nhnxt:Tlphcbanukhngphhptheoktqukhngsinh (41,3%)caohntlphcbanuphhp(32,6%).Phcbanukhng xc nh c c ph hp hay khng do khng sinh s dng trong phc khng c lm khng sinh chim 26,1%. 35 CHNG 4. BN LUN 4.1.C IM CA BNH NHN VPTM Trongkhongthigiantthng1/2012nthng12/2012c46bnhnhn ti khoa Hi sc cp cu bnh vin a khoa c Giang c chn vo nghin cu ca chng ti. T l bnh nhn nam (63,0%) cao hn so vi bnh nhn n (37,0%), tng t nh kt qu nghin cu ca Kotgire S. A. (2011), Goel V. (2012), v Phm Hng Trng (2009) (t l bnh nhn nam ln lt l 61,53%, 69,81%, 81,63%) [9, 30, 41]. Nhiu nghin cu chng minh rng tui 60, COPD, t li ni kh qun, angtngthngddy,angdngthucdphnglotddydostressl nhngyutnguycmcVPTM[18,26,36].Ccbnhnhntrongnghincu ucnguyccaomcVPTM.Tuitrungbnhca46bnhnhntrongnghin cu l 76 11 cao hn so vi nghin cu ca Phm Hng Trng (2009) 61 20, tuy nhin kh tng ng vi nghin cu ca Kotgire S. A. v cng s (2011) 75 18 [9, 41]. Nhm tui t 60 n 79 chim t l cao nht trong nghin cu ca chng ti (50,0%). Tuy nhin, cc bo co v tui mc VPTM dao ng rt khc nhau. NghincucaVcnhtibnhvinE(2005)chothy VPTMgpbnh nhntrn60tuil56,09%[5].Trongkhi,theonghincucaPhmThi Dng ti bnh vin 103 (2013), tui t 40 n 59 chim t l cao nht (41,27%), bnh nhn trn 60 tui ch chim 25,4% [6]. Tn s mc COPD ca cc bnh nhn trongnghincuchngtil30,4%caohnsoviktqunghincutibnh vin 175 (2009) (8,16%) [9]. iu ny c th do m hnh bnh tt hai bnh vin l khc nhau. 100% bnhnhntrongnghincu angtngthngddy,ktqu ny cao hn so vi nghin cu ca Erbay R.H. v cng s (2004) (81,1%), nhng tngtnhktqu caYangY.S.cngcngs(2013)(96,9%)[26,61].Vic nui dng qua ng thng d dy c th lm gia tng s xm nhp ca vi khun vnghuhng,tngnguyctrongcdchddyvhtphicctcnhngy 36bnh vo ng h hp di, t lm tng nguy c vim phi [20]. Mt s nghin cu cng kt lun, nui dng qua sonde d dy ko di l yu t nguy c c lpcaVPTM[6,9].Tldphnglotddydostressvthigianthmy trungbnhcatrongnghincucachngtillnltl60,9%,13,8ngy, tng t nh kt qu ca Phm Hng Trng (2009) (59,18%, 14 ngy) [9].Phn ln cc bnh nhn trong nghin cu ca chng ti c chn on mc cc bnh l thn kinh trung ng khi nhp khoa (50,0%), kt qu ny tng t nh nghin cu ca Phm Thi Dng (2013) (53,98%) [6].Trong nghin cu ca chng ti, t l bnh nhn c kt qu iu tr , gim bng t l bnh nhn c kt qu nng hn (41,3%) v khng c trng hp t vong nocghinhn.iunycthdohuhtccbnhnhnctnhtrngnng hn hoc khng thay i, gia nh bnh nhn u xin xut vin. Trong khi , t l t vong mt s nghin cu l kh cao. Theo nghin cu bnh vin 175 (2009) t l ny l 32,65%, bnh vin 103 ( 2013) l 23,81% [6, 9]. Tuy nhin, t l nhm bnhnhnnnghnvkhngthayitrongnghincucachngti(58,7%) tng t vi t l nhm bnh nhn t v iu tr tht bi trong nghin cu bnh vin 103 (58,73%) [6]. 4.2.CN NGUYN GY VIM PHI LIN QUAN N TH MYTrong nghin cu ca chng ti, bnh phm u l m ni kh qun v t l cy m ni kh qun dng tnh l 94,2%, t l phn lp c 2 tc nhn gy bnh l 19,6%. Nghin cu bnh vin 175 (2009) cho kt qu tng t, t l cy dng tnh l 89,80% v t l phnlp t 2 vi khun tr ln l 18,18% [9].Tc nhn gy VPTM thng gp trong nghin cu ca chng ti l cc chng Gram m c bit l A. baumannii, K. peumoniae, E. coli v P. aeruginosa. Trong ,haivikhunchyunhtlA.baumannii(36,4%),K.peumoniae(16,4%) tngtnhktqunghincucaTrnHuThng(2012)(40%,19,4%)v PhmHngTrng(2009)(37,50%,21,43%)[8,9].iunycngphhpvi tnh hnh nhim khun nc ta hin nay. Theo bo co t hot ng theo di s 37khng khng sinh ca vi khun gy bnh thng gp nm 2005, tnh chung trn c nc, A. baumannii v K. pneumoniae l hai vi khun gy cc bnh l nhim trng ph bin nht [11]. Khi xt v thi gian VPTM, nhiu nghin cu kt lun rng VPTM mun thnggyrabiccvikhunakhng(MDR)baogmP.aeruginosa, Acinetobacter spp., S. aureus khng vi methicillin [35, 59]. Trong nghin cu ca chng ti, vi khun gy VPTM mun ph bin nht lA. baumannii (30,4%), ng thhailE.coli(15,2%),tiplK.pneumoniae(13,0%)vP.aeruginosa (10,9%). iu ny ph hp vi nhn nh trn ng thi cng tng t nh kt qu ca cc nghin cu trong nc nh: nghin cu ca Phm Hng Trng (2009), Phm Thi Dng (2013) [6, 9]. Tuy nhin, cc vi khun khng thuc xut hin c bnh nhn VPTM sm trong nghin cu ca chng ti: A. baumannii (13,0%), K. pneumoniae(6,5%),S.aureus(2,2%).Ktqunytngtnhnghincuca PhmHngTrng(2009),VPTMsmthngdoA.baumannii(8,92%), Klebsiella spp. (7,14%), S.aureus (3,57%), P.aeruginosa (3,57%) v kt qu nghin cucaTrnHuThngcngcngs(2012),K.pneumonia(25,0%),P. aeruginosa(16,7%),A.baumannii(16,7%),S.aureus(16,7%)[8,9].Vicccvi khun khng thuc xut hin bnh nhn VPTM sm cng tr thnh mt mi quan tm ln trong iu tr hin nay. 4.3.TNH HNH KHNG KHNG SINH CA MT S VI KHUN GY BNH THNG GP4.3.1.Tnh hnh khng khng sinh ca Acinetobacter baumannii CcloiAcinetobactercbitlAcinetobacterbaumanniictckhng thuc nhanh chng. Vo nhng nm 1970, A. baumannii c cho l nhy cm vi huhtkhngsinhthhinnaytcnhngybnhnyxuthinkhngvi phn ln cc khng sinh ang c s dng v tr thnh mt trong nhng tc nhn chnhgynhimtrngbnhvintrntonthgii[29].Ccdliuththng gimstqucgiavnhimtrngbnhvinHoaKchothy7%cctrnghp 38nhim trng bnh vin ti khoa iu tr tch cc nm 2003 l do Acinetobacter spp., trong khi vo nm 1986 con s ny ch l 4% [32].Ti Vit Nam, theo bo co t hot ng Theo di s khng khng sinh ca vi khun gy bnh thng gp Vit Nam nm 2005, A.baumannii ng th haitrongs5vikhungybnhthnggp[11].Vikhunnykhngcao vicckhngsinhthngdngiutrcctrckhunGrammnh: ceftriaxon,ceftazidim,piperacillin/tazobactam,ciprofloxacin,gentamycin, amikacin. T l khng cc khng sinh ny ca A. baumannii trong nghin cu ca chng ti tng t nh cc nghin cu khc trong nc v trn th gii c trnh by trong bng 4.1.Bng 4.1. T l (%) khng khng sinh ca A. baumannii trong mt s nghin cu Khng sinhNghin cu ca chng ti BV 175 (2009)[9] BV Bch Mai (2012) [8] Yang Y. S. v cng s (2013) [61] Ceftazidim90,01007596,9 Ceftriaxon94,7*** Imipenem80,068,458,349,0 Meropenem100,0100,058,3* Ampicilin/Sulbactam90,0100,058,365,3 Piperacilin/Tazobactam80,095,066,780,2 Ciprofloxacin88,990,57596,9 Levofloxacin64,7*** Gentamicin88,9100,0*93,6 Tobramycin88,2*** Amikacin90,089,566,789,6 Ch thch: * khng c bo co 39Hinnay,carbapenemvnlmttrongnhnglachnchoiutrnhim trngdoA.baumanniiakhngthuc[59].Tuynhin,skhngcavikhun nyvivicarbapenemtnglnrtnhiutrntonthgii[22,58].TiVit Nam, theo kt qu ca cc nghin cu c trnh by bng 4.1 cho thy mc khngimipenemcaA.baumanniidaongt58,3%n68,4%vvi meropenem dao ng t 58,3% n 100,0% [8, 9]. Trong nghin cu ca chng ti, 80,0%ccchngA.baumanniikhngviimipenem,tl ny cao hnsovi cc nghin cu c trnh by trong bng 4.1. T l khng meropenem trong nghin cu ca chng ti l 100,0% ph hp vi kt qu ca Phm Hng Trng (2009), nhngchc2chngA.baumanniiclmkhngsinhvimeropenemnn kt qu ca chng ti ch mang tnh cht tham kho [9]. 4.3.2.Tnh hnh khng khng sinh ca Pseudomonas aeruginosa P.aeruginosalmttcnhnquantrnggynhimtrngbnhvin,chim 10% cc trng hp nhim trng mc phi ti bnh vin. ng thi, n cng l mt trongnhngnguynnhnhngugyVPTMvinguyctvongt34%n 68%. Nhim trng do P. aeruginosa thng nng, kh iu tr v chng c c tnh cao v khng vi nhiu loi khng sinh [25]. Nhn chung, vi khun ny khng cao vi nhiu khng sinh: 80,0% vi ciprofloxacin,gentamycin,tobramycin,amikacinvkhong60,0%viceftazidim (bng 4.2). T l khng imipenem trong nghin cu ca chng ti l 60,0% cao hnsoviccnghincunm2013,2012,2009(4,76%;47,06%;28,6%)(bng 4.3)tuynhintngtnhktqucaRochaL.A.vcngs(2008)(52,0%) [53].Nhvycth thytnhkhngthuccaP.aeruginosathayikhcnhau theo tng khu vc v tng thi k. Vic iu tr khng sinh theo kinh nghim ban u ngoi cn c vo cc hng dn cn phi da vo m hnh v tnh khng thuc cacctcnhngybnhtiaphng.TheomthngdncaAnh(2008), iutrVPTMnghinghocdoP.aeruginosacthlachncckhngsinh: ceftazidim,ciprofloxacin,meropenemhaypiperacilin/tazobactam[45].Trong 40nghin cu ca chng ti, t l vi khun ny khng piperacilin/tazobactam (25,0%) thp hn nhiu so vi cc khng sinh cn li (bng 4.3), nh vy ti khoa Hi sc cp cu- bnh vin a khoa c Giang, nu nghi ng VPTM do P. aeruginosa c th u tin la chn piperacilin/tazobactam trong phc iu tr kinh nghim ban u. Bng 4.2. T l (%) khng khng sinh ca P. aeruginosa trong mt s nghin cu Khng sinhNghin cu ca chng tiBV 175 (2009)[9] BV 103 (2013) [6] Goel V. v cng s (2012) [30] Ceftazidim60,085,757,1435,29 Imipenem60,028,64,7647,06 Ticarcilin/acid clavulanic0*9,52* Piperacilin/Tazobactam25,0100*23,53 Ciprofloxacin80,071,461,9082,35 Gentamicin100,010085,71100 Tobramycin100,0*** Amikacin80,071,443,4782,35 Ch thch: *: khng c bo co 4.3.3.Tnh hnh khng khng sinh ca Klebsiella pneumoniae, E. coliVic a cc cephalosporin th h ba vo thc hnh lm sng trong u nhng nm 1980 to ra mt bc t ph ln trong cuc chin chng li cc vi khun tit-lactamasekhngkhngsinh.Tuynhin,bocoutinvmen- lactamase ph rng (ESBL) c kh nng thy phn cc cephalosporin ph rng xut hin ti c vo nm 1983, tip l Anh, Php v nhanh chng c bit n trn ton th gii [48]. Cc vi khun ng rut (Enterobacteriaceae) c bit l K. pneumoniae v E. coli l nhng vi khun tit ESBL thng gp nht. y cng l cc tc nhn quan trng gy nhim trng mc phi ti bnh vin nh: nhim trng 41ng tiu, mu, vim phi v nhim trng bng. Cc gen m ha cho ESBL tm thytrnplasmidthnglccgenmhakhngquinolon,aminoglycosid, sulfonamid [56]. V vy, vic iu tr cc chng tit ESBL gp rt nhiu kh khn [48]. Bng 4.3. T l (%) khng khng sinh ca K. pneumoniae trong mt s nghin cu Khng sinhNghin cu ca chng ti Phm Hng Trng (2009) [9] Gupta A. v cng s (2011) [31] Ceftazidim71,490,085,7 Cefepim50,0** Imipenem25,020,014,3 Ertapenem0** Amoxicilin/acid clavulanic87,5** Ticarcilin/acid clavulanic37,5** Piperacilin/Tazobactam28,610057,1 Ciprofloxacin33,375,0* Levofloxacin50,0*71,4 Gentamicin42,990,085,7 Tobramycin52,6*85,7 Amikacin44,475,071,4 Ch thch: *: khng c bo co. Trongnghincucachngti,tlkhngcaE.colivicc cephalosporinthh3,aminoglycosidutrn80%tramikacin(50,0%),vi fluoroquinolon t l ny l trn 75% (bng 4.4). Trong khi , mc khng thuc ca K. pneumoniae phn lp c trn 46 bnh nhn thp hn mc khng thuc ca E. coli v cc nghin cu khc (bng 4.3). T l khng aminoglycosid, quinolon 42caK.pneumoniaeudi53,0%,ticarcilin/acidclavulanic(37,5%),cefepim (50,0%), piperacilin/tazobactam (28,6%) (bng 4.3). Bng 4.4. T l (%) tnh khng khng sinh ca E. coli trong mt s nghin cu Khng sinhNghin cu ca chng ti BV 103 (2013) [6] BV Bch Mai (2007) [7] Ceftazidim87,5 *42,9 Cefotaxim10084,61 * Cefepim10038,4628,6 Imipenem42,9014,3 Ertapenem00* Amoxicilin/acid clavulanic62,5 53,8557,1 Ticarcilin/acid clavulanic50,0*83,3 Piperacilin/Tazobactam0*16,7 Ciprofloxacin75,053,8571,4 Ofloxacin83,361,54 * Gentamicin85,7*85,7 Tobramycin83,3*71,4 Amikacin50,0 7,69 40,0 Ch thch: *: khng c bo co. Hin nay, carbapenem c coi l khng sinh c tc dng iu tr tt nht vi ccvikhuntitESBL[48].Tuynhin,mtvnnglongiltlkhng imipenem ang gia tng ng k. Theo bo co t hot ng Theo di s khng khng sinh ca vi khun gy bnh thng gp Vit Nam trong 6 thng u nm 2006,tlkhngimipenemcaE.colil1,5%,K.pneumoniael1,2%trnc nc,ringbnhvinakhoatnhngThp,consnyl11,4%viE.coli, 5,3% vi K. pneumoniae [12]. Trong nghin cu ca chng ti, 42,9% E. coli khng imipenem,caohntltrungbnhtrncnccngnhccnghincukhc (bng 4.4). iu ny c th l do s gia tng nhanh chng tnh khng thuc ca E. 43coli v c th do s lng vi khun ny c lm khng sinh vi imipenem t (7 chng).Tuynhin,khngcchngE.colinotrongnghincucachngti khngertapenem,tngtktqucaPhmThiDng(2013)[6].Tlkhng ertapenemcaK.pneumoniaetrn46bnhnhncachngticngl0%.Trong khi,tlkhngimipenemcavikhunnyl25,0%,caohnktqucaGuptaA.cngcngs(2011)(14,3%),nhngkhtngtktqucaPhm Hng Trng (2009) (20,0%) [9, 31].4.4.TNH HNH S DNG KHNG SINH TRN BNH NHN VPTM4.4.1.Tnh hnh s dng khng sinh trn bnh nhn VPTM Trong nghin cu ca chng ti, ceftriaxon l khng sinh c ch nh nhiu nht (22,0%). y l mt cephalosporin th h ba c hot ph rng. Tc dng dit khun ca n l do c ch s tng hp thnh t bo vi khun. Ceftriaxon bn vng viascc-lactamase(penicilinasevcephalosporinase)caccvikhun Gram m v Gram dng [3]. Khng sinh c s dng ph bin sau ceftriaxon l levofloxacin(21,3%)vciprofloxacin(12,8%).Chaikhngsinhnyul fluoroquinolon dit Pseudomonas (antipseudomonal fluoroquinolon) [21]. Tip n lpiperacilin/tazobactam(9,9%).Hiuquvantoncakhngsinhnytrong iu tr VPTM c chng minh [16]. Phc1khngsinhcsdngnhiunhttrnbnhnhnVPTMl cephalosporin th h 3 (61,3%). Tuy nhin, phn ln cc phc cephalosporin th h 3 c bit l ceftriaxon c dng trong phc trc khi c chn on VPTM. Theo hip hi lng ngc Hoa K (2005), mc d vic s dng khng sinh t trc cthlmgimnguycnhimkhunbnhvinmtvinhmbnhnhn,tuy nhin, nhng bnh nhn c tin s dng khng sinh trc khi khi pht nhim trng cnnghingnhimcctcnhnakhngthuc.ngthi,hiphinycng khuyn co rng khng sinh d phng cho VPTM khng nn c s dng thng xuyn cho n khi cc d liu c sn [59]. 44Phc phi hp 2 khng sinh ph bin nht trn bnh nhn VPTM l kt hp giacephalosporinthh3vfluoroquinolon(57,8%).ycnglphc2 khng sinh c s dng nhiu nht trong phc trc khi chn on VPTM v phcbanukhicchnonVPTM,cbitlphihpgiaceftriaxon+ levofloxacin. Trong khi , phc 2 khng sinh ch yu trong phc thay th l piperacilin/tazobactam + levofloxacin (10,9%). iu ny c th do s thay i iu tr ca bc s khi c kt qu khng sinh . A. baumannii, K. pneumoniae, E. coli, P. aeruginosa l 4 vi khun c phn lp nhiu nht trong nghin cu ca chng ti, chim76,4%tng stcnhngybnhphnlpc.Tlkhngceftriaxon caccvikhunnyurtcao:E.coli(100%),P.aeruginosa(100%),A. baumannii(94,7%),K.pneumoniae(62,5%).Ngcli,tlkhngcaccvi khunnyvipiperacilin/tazobactamtngithp:E.coli(0%),P.aeruginosa (25,0%), K. pneumoniae (28,6%) tr A. baumannii l 80,0%, nhng ch c 50% cc chng A. baumannii c lm khng sinh vi piperacilin/tazobactam. 4.4.2.La chn khng sinh trong phc ban u iu tr VPTM Cc phc khng sinh thng gp trong phc ban u Phc ban u c s dng trn cc bnh nhn ca chng ti khi c chn on VPTM phn ln l phc kt hp khng sinh (69,6%), trong phi hp 2 khng sinh l ch yu (65,2%). Theo hng dn iu tr ca hip hi lng ngc Hoa K (2005), phc kinh nghimban u cho cc bnh nhn VPTM mun thng dngliuphpphihpkhngsinh.iunyldoVPTMmunchyudocc tcnhnakhngthucnh:P.aeruginosa,K.pneumoniaesinhESBL, Acinetobacter spp., khi vic kt hp iu tr s cung cp mt phc theo kinh nghim ph rng c kh nng bao gm t nht mt thuc c hot tnh chng li cc tcnhngybnhakhngthucthnggpny[59].TlbnhnhnVPTM mun trong nghin cu ca chng ti l 71,7%, tng i ph hp vi s phc kt hp a khng sinh c s dng (69,6%). Ceftriaxon+ levofloxacin l phc phi hp ph bin nht trong s cc phc phi hp (21,7%), tip l phi hp 45giaceftriaxon+ciprofloxacin(15,2%).Tuynhin,theohngdncaBYT (2013)v hiphilngngcHoaK(2005),nusdngphc phihpgia cephalosporin v fluoroquinolon iu tr theo kinh nghim cho bnh nhn VPTM mun,thcephalosporinckhuyncosdnglcefepimhocceftazidim[4, 59].Trong mt phn tch meta v tng quan h thng, Aarts M.A. cng cng s ch ra rng n tr liu c hiu qu khng km hn so vi phc phi hp khng sinh [13]. Hng dn ca hip hi lng ngc Hoa K (2005) v mt hng dn ca Anh(2008)khuyncorngntrliunncsdngkhicthvphc phihpthngthnvkhngcnthitnhiubnhnhn[45,59].Trong nghincucachngti,phcmtkhngsinhcsdngnhiunhtl cefoperazon/sulbactam(8,7%).TheoHigginsPG.vcngs,sulbactamchot tnhkhngkhuntrongngnghimvttrihnsoviacidclavulanic, tazobactamvcthlmtlachniutrchoccbnhnhimtrngA. baumannii a khng thuc [33].Phc ban u theo thi im chn on VPTM Trong nghin cu ca chng ti, iu tr VPTM sm tp trung ch yu vo 2 phc : cephalosporin th h 3 + fluoroquinolon v cephalosporin th h 3. Trong khi , ngoi 2 phc ny, iu tr VPTM mun cn s dng nhiu phc khc nh: cephalosporin th h ba + aminogycosid (4,3%), carbapenem + fluoroquinolon (2,2%), penicilin (piperacilin/tazobactam) + fluoroquinolon (2,2%). y u l cc phc c hip hi lng ngc Hoa K (2005) khuyn co trong iu tr ban u choVPTMmun.Bncnh,chngticngnhnthyrngccbnhnhn VPTMmuncchnhfluoroquinolonnhiuhnsovinhmVPTMsm. iu ny c th l do phn ln cc trng hp VPTM mun u c ch nh liu php phi hp khng sinh c s kt hp ca mt fluoroquinolon vi mt khng sinh khcnh:penicilin+fluoroquinolon,carbapenem+fluoroquinolon,peptid+ fluoroquinolonvcephalosporinthh3+fluoroquinolon.Ccfluoroquinolon c dng l ciprofloxacin v levofloxacin. Sinh kh dng ca cc quinolon ng 46ungtngngvingtnhmch.iunystoiukinthunlicho vic chuyn quinolon t ng tnh mch sang ng ung nhng bnh nhn p ng lm sng tt m vn m bo hiu qu iu tr ng thi tch kim c chi ph [59].S ph hp ca phc ban u theo kt qu khng sinh iu tr khng sinh ban u theo kinh nghim ph hp l mt vn c nhiu thch thc hin nay. Vic iu tr ban u khng thch hp va khng tiu dit c cc tc nhn gy bnh va to iu kin cho cc vi khun ny lan truyn v gia tng tnh khng thuc ng thi gp phn lm tng chi ph iu tr, tng cc bin chng lin quan n iu tr [59]. Trong ngin cu ca chng ti, t l phc khng sinh banuphhpvikhngsinhl32,6%,caohnsoviktqucaPhm Hng Trng (2009) (22,72%) [9]. Tuy nhin, t l ny cn phi tip tc c nng caohn.Biv,viclachnkhngsinhbanuphhpcvaitrquantrng trongiutrVPTM.Ccnghincutrnthgiichngminhrngiutr khng sinh ban u khng ph hp c lin quan n vic tng t l t vong bnh nhn, ko di thi gian th my v thi gian nm vin [22, 24, 35, 45]. Nghin cu ca Phm Hng Trng (2009) cng cho thy t l t vong nhm iu tr khng sinh khng ph hp (22,44%) cao hn nhm iu tr ph hp (10,20%), nhng kt qu ny khng c ngha thng k (p > 0,05). Tuy nhin, nghin cu ny cng ch ra rng nhm iu tr khng ph hp c thi gian th my (88,23%) nhiu hn nhm iu tr ph hp (11,76%) (p < 0,05) [9]. 47KT LUN V XUT 1.KT LUN Qua kho st vic s dng khng sinh trn 46 bnh nhn VPTM c iu tr ti khoa Hi sc cp cu bnh vin a khoa c Giang t thng 1/2012 n thng 12/2012 chng ti rt ra mt s kt lun sau: 1.1.V c im chung ca bnh nhn nghin cu Tui trung bnh ca cc bnh nhn VPTM trong nghin cu l 76. Cc bnh nhnucnguyccaomcVPTM.BnhlchyukhinhpkhoaHi sc cpculbnhlTKTW(50,0%).PhnlncctrnghplVPTM mun (71,7%). 1.2.Vcimcatcnhngybnhvtnhkhngkhngsinhcaccvi khun gy bnh ph bin TcnhngybnhVPTMchyulccvikhunGramm,thnggp nhtlcctcnhnakhngthucnhA.baumannii(36,4%),K. pneumoniae (16,4%), E. coli (14,5%) , P. aeruginosa (9,1%). C VPTM sm v VPTM mun u c hnh nh vi khun ch yu l cc vi khun a khng thuc. A. baumannii v P. aeruginosa u khng mnh vi cc khng sinh, ngoi tr piperacilin/tazobatam l cn nhy cm cao vi chng P. aeruginosa (t l khngl25,0%).E.coli,K.pneumoniaecngctlkhngcaovi nhiukhngsinh,ngoitrpiperacilin/tazobactam.TlkhngcaE. coli vi piperacilin/tazobactam l 0% v K. pneumoniae l 28,6%. 1.3.V liu php khng sinh c s dng trn bnh nhn VPTM Cc khng sinh c s dng nhiu nht l ceftriaxon (22,0%), levofloxacin (21,3%).Cephalosporinthh3lphc1khngsinhphbinnhtl 48(61,3%) v phc 2 khng sinh c s dng nhiu nht l cephalosporin th h 3 phi hp vi fluoroquinolon. Phnlnphcbanulphckthp2khngsinh(65,2%)vch yulkthpceftriaxon+levofloxacin(21,7%).Trongkhi,phc csdngnhiunhttrongphcthaythvphctrckhichn on VPTM ln lt l piperacilin/tazobactam (17,4%), ceftriaxon (47,8%). PhcbanuphbintrongVPTMsm,VPTMmunulphc phihpgiacephalosporinthh3vfluoroquinolon(lnltl17,4%; 32,6%).Tlphcbanukhngphhptheoktqukhngsinh (41,3%) cao hn t l phc ban u ph hp (32,6%). 2. 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(2012), "Respiratory Review of 2012: Pneumonia", Tuberculosis and Respiratory Diseases, 73, pp. 77-83. PH LC 1 Bng 1.1: Bng im nh gi nhim khun phi ca Pugin (CPIS) im Triu chng 012 1.Dch tit ph qun tNhiuNhiu, m 2.Thm nhim trn X- quangKhngLan taKhu tr 3.Nhit 36,5 38,4 38,5 38,9 39 hoc 36 4.Bch cu (G/L)4 - 11< 4 hoc > 11 < 4 hoc > 11 v BC a > 500 5.PaO2/FiO2 >240 hoc c ARDS 240vkhng c ARDS 6.Cy khun dch ph qun m tnhDng tnh

Bng 1.2: Bng im nh gi nhim khun phi ca Schurink im Triu chng 012 1.Nhit (oC)36,1 to 38,538,5 v 38,9 39 hoc 36 2.Bch cu(G/l)4 BC 11 < 3,9 hoc 11240 hoc c ARDS 240vkhng c ARDS 5.Thmnhimmi trn X-quang phi Khng Lan ta, nhiu nt Khu tr PH LC 2 HNG DN LA IU TR VPTM CA B Y T (2013) Bng 2.1. Hng dn la chn khng sinh ban u cho vim phi bnh vin khi cha c kt qu vi khun hcPhn loi Nguyn nhn chnh Khng sinh la chn Nm vin 2-5 ngy Vim phi nh, va hoc nng v nguy c thp Enterobacteriaceae, S. pneumoniae,H. infuenzae,S. aureus nhy cm methicilin. Beta-lactam + c ch betalactamase (piperacilin + tazobactam, ticarcilin + clavulanat), hoc ceftriaxon, hoc fluoroquinolon C th kt hp 1 aminoglycosid Nm vin > 5 ngy Vim phi nh, va Tng t nm vin 2-5 ngy Nm vin 5 ngy Vim phi nng v nguy c thp hoc P. aruginosa,cc chng Enterobacter,cc chng Acinetobacter. Carbapenem hoc nhm beta-lactam+ c ch betalactamase (piperacilin + tazobactam, cefoperazol+sulbactam),Hoc cefepim Nm vin 2 ngyVim phi nng v nguy c cao Carbapenem hoc beta-lactam+ c ch betalactamase (piperacilin + tazobactam, cefoperazol+sulbactam), hoc cefepim. Kt hp vi amikacin hoc fluoroquinolon. Trng hp c bit Gn y c phu thut bng hoc c b sc vo phi. Vi khun k kh Beta-lactam + c ch betalactamase (piperacilin + tazobactam, cefoperazol+sulbactam) hoc clindamycin + metronidazol (nu d ng vi cc thuc trn) Nhim S. aureus khng methicilin cc v tr khc. C dng khng sinh chng S. aureus trc S. aureuskhng methicilin Nh bng2.2 Nm khoa Hi sc ko di Dng khng sinh ph rng trc Bnh cu trc phi P. aeruginosaNh bng 2.2 Nguy c cao: tui 65, vim ty, bnh phi tc nghn mn tnh, bnh l thn kinh (t qu, qu liu thuc, hn m, bi lit), suy tim xung huyt, suy dinh dng, i thong,ctnikhqun,suythn,phuthutngc,bng,nghinru. Nhng trng hp khc c xem l Nguy c thp. Bng 2.2. Hng dn la chn khng sinh khi c kt qu vi khun hc cho vim phi bnh vin Chng vi khunThuc la chn ban uThuc thay th S. aureus nhy cm methicilin Oxacilin hoc cephalosporin th h 1 rifampicin cefotaxim, ceftriaxon, fluoroquinolon, trimethoprim-sulphamethoxazol, clindamycin S. aureuskhng methicilin Vancomycin hoc linezolid rifampicin, hoc teicoplanin fluoroquinolon, trimethoprim-sulphamethoxazol, linezolid (ty theo khng sinh ) K. pneumoniaev ccEnterobacteriaceae khc(ngoi tr Enterobacter) Beta-lactam + c ch betalactamase (piperacilin + tazobactam,cefoperazol+sulbactam), cephalosporins th h 3, cefepim aminoglycosid; carbapenem fluoroquinolon, aztreonam EnterobacterImipenem + cilastatin, beta- cephalosporin th h 3lactam + c ch betalactamase (piperacilin + tazobactam, ticarcilin + clavulanat), cefepim, fluoroquinolon, aminoglycosid + aminoglycosid Vi khun Gram m sinh ESBL Imipenem + cilastatin, meropenem P. aeruginosaBeta-lactam khng Pseudomonas (ceftazidim, cefepim) + aminoglycosid;Carbapenem + aminoglycosid fluoroquinolon+ aminoglycosid fluoroquinolon+ beta-lactam khng Pseudomonas (ceftazidim, cefepim) AcinetobacterAminoglycosid + piperacilin hoc imipenem + cilastatin Colistin cho Acinetobacter khng carbapenem Ch:Khisdngthucnhmcephalosporinkthpvithucnhm aminoglycosid cn theo di chc nng thn ca ngi bnh 2 ln/ tun. PH LC 3 HNG DN LA CHN KHNG SINH BAN U TRONG IU TR VPTM THEO HIP HI LNG NGC HOA K (2005) Biu 3.1. Hng dn la chn khng sinh ban u trong iu tr VPTM. Bng 3.1. Cc yu t nguy c nhim cc vi khun a khng thuc. -C dng khng sinh trong 90 ngy trc y. -Hin ang nm vin 5 ngy hoc nm vin > 2 ngy trong 90 ngy trc y. -Tnsutkhngkhngsinhcaotrongcngnghoctrongkhoaangnm iu tr. -C bnh suy gim min dch v/ hoc s dng cc thuc c ch min dch. -Sng trong cc nh iu dng. -C tim truyn tnh mch hoc chm sc vt thng ti nh. -C lc mu trong vng 30 ngy. -Cc thnh vin trong gia nh c nhim cc vi khun a khng thuc. Liu php khng sinh ban u trong iu tr VPTM VPTM mun ( 5 ngy) hoc c nguy c nhim VK a khng thuc (bng 3.1) KhngC Khng sinh ph nh hng (bng 3.2) Khng sinh ph rng (bng 3.3) Bng 3.2. Liu php khng sinh ban u cho nhng bnh nhn VPTM sm khng c nguy c nhim VK khng thuc. Vi khun nghi ngKhng sinh la chn*Streptococcus pneumoniae** Haemophillus influenzae Staphylococcus aureus nhy cm vi methicillin Trc khun Gram m vn cn nhy cm vi khng sinh Escherichia coli Klebsiella pneumoniae Enterobacter spp Proteus spp Serratia marcescens Ceftriaxon hoc Levofloxacin, Moxifloxacin, hoc Ciprofloxacin hoc Ampicillin/Sulbactam hoc Ertapenem * Xem bng 3.4 v liu lng khng sinh ban u ph hp ** Cc chng S. pneumoniae khng vi penicillin v S. pneumoniae a khng ngy cngphbin.Levofloxacinvmoxifloxacincutinlachnhn ciprofloxacin. Bng 3.3. Liu php KSB cho nhng bnh nhn VPTM c nguy c nhim VK a khng thuc, VPTM mun v cc bnh nhn c tnh trng nng. Vi khun nghi ngKS la chn* - VK trong bng 3.2 v nhng VK a khng Pseudomonas aeruginosa Klebsiella pneumonia (ESBL+)** Acinetobacter baumanii** Staphylococcus aureus khng methicillin - Legionnella pneumophila** Cephalosporin (Cefepim, ceftazidim) hocCarbapenem (imipenem hay meropenem) hoc -lactam/c ch -lactamase (piperacillin/tazobactam) Kt hp vi : Fluroquinolon (ciprofloxacin, levofloxacin) hoc Aminoglycosid (amikacin, gentamicin, tobramycin) hoc linezolid hoc vancomycin*** *Xembng 3.4 v liu lng khng sinh ban u ph hp. Liu php khng sinh banunncthayihayhiuchnhchophhpktqukhngsinhv p ng lm sng trn bnh nhn. **NuVKnghinglchngtitmen-lactamasephrng(EBLS)nh KlebsiellapneumoniahocAcinetobacterspp.thnnlachnKSnhm carbapenem.NunghingVPBVdoL.pneumophilaliuphpkhngsinhphi hpnndngKSnhmmacrolid(vdnhazithromycin)hocfluroquinolon (ciprofloxacin, levofloxacin) hn l s dng aminoglycosid. *** Nu c nguy c nhim S.aureus khng methicilin. Bng3.4.Liulngkhngsinhbanungtnhmchchonhngbnh nhn VPTM c nguy c nhim VK khng thuc, VPTM mun. Khng sinhLiu lng* Cephalosporin Cefepim Ceftazidim Carbapenem Imepenem Meropenem -lactam/c ch -lactamase Piperacillin/tazobactam Aminoglycosid Gentamycin Tobramycin Amikacin Quinolon Levofoloxacin Ciprofloxacin Vancomycin Linezolid 1-2g/8-12 gi 2g/8 gi 500mg/6 gi hoc 1g/8 gi 1g/8 gi 4,5g/6 gi 7mg/kg/ngy** 7mg/kg/ngy** 20mg/kg/ngy** 750mg/1 ngy 400mg/8 gi 15mg/kg/12 gi 600mg/12 gi * Liu thuc s dng cn c trn chc nng gan v thn. **Nngycagentamycinvtobramycinphinhhn1g/mlvvi amikacin phi nh hn 4-5g/ml. *** Nng y ca vancomycin nm trong khong 15-20 g/ml. PH LC 4 PHIU THU THP THNG TIN BNH N I-C IM BNH NHN: 1.H v tn bnh nhn 2.M bnh nhn 3.Tui 4.Cn nng 5.Gii Nam N 6.Ngy nhp vin 7.Ngy ra vin 8.Ngy nhp khoa ICU 9.Ngy ri khoa ICU 10. Chn on lc nhp vin -Bnh chnh: -Bnh mc km: 11.Thi im bt u th my12.Thi im kt thc th my13.Thi im chn on VAP 14. Cc yu t nguy c Tui 60 COPD t li ni kh qun ang t ng thng d dy ang s dng thuc d phng lot d dy do stress15. Kt qu iu tr Khi Khng thay i , gim Nng hn T vong II-C IM LM SNG V CN LM SNG CA BNH NHN: 1.Lm sng: Ch sKt qu Ngy NgyNgyNgy Mch (ln/pht) HA tm thu/ HA tm trng (mmHg) Nhit (0C) Nhp th (ln/pht) Tnh cht m im Glasgow 2.Cn lm sng: a.Xt nghim cng thc mu: Ch s Kt qu Ngy Ngy Ngy NgyS lng bch cu (WBC) (G/L) Bch cu trung tnh (NEUT) (G/L) b.Xt nghim sinh ha mu: Ch s Kt qu Ngy Ngy Ngy NgyUre (mmol/l) Creatinin (mol/l) CRP (mg/L) in gii Na+ (mmol/L)K+ (mmol/l) c.X-quang phi: Kt qu NgyNgyNgy d.Kh mu ng mch: Ch s Kt qu Ngy Ngy Ngy NgypH PCO2 (mmHg) PO2 (mmHg) HCO3- (mmol/L) FiO2 (%) Pa O2/ FiO2 (mmHg/%) e.Xt nghim vi sinh: Bnh phmNgy xt nghim Ngy tr kt qu m tnh/ dng tnh Vi khun III-IU TR 1.Khng sinh: -Khng sinh s dng trc khi c khng sinh : STT Tn bit dc Tn hot cht Liu dng ng dng Ngy bt u dng Ngy kt thc S ngy s dng -Khng sinh s dng sau khi c khng sinh : STT Tn bit dc Tn hot cht Liu dng ng dng Ngy bt u dng Ngy kt thc S ngy s dng KT QU KHNG SINH -Bnh phm: -Ngy gi mu: Ngy nhn kt qu: -Chng vi khun lm khng sinh : Khng sinhSIRKhng sinhSIR PenicillinImipenem AmpicillinMeropenem AmoxicillinDoripenem Amoxicilin/acid clavulanicClindamycin Ampicilin/sulbactamChloramphenicol Ticarcillin/acid clavulanicErythromycin Piperacillin/tazobactamTetracyclin AztreonamNalidixic acid VancomycinNofloxacin Oxacillin/ph cuCiprofloxacin CefazolinOfloxacin CephalothinLevofloxacin CefuroximGentamicin CefoxitinTobramycin CeftazidimAminkacin CefotaximNetilmicin CeftriaxonCo-trimoxazol CefoperazonColistin Cefoperazon/sulbactamMetronidazol CefepimFosfomycin ErtapenemNitrofurantoin DANH SCH BNH NHN NGHIN CU TI KHOA HI SC CP CU BNH VIN A KHOA C GIANG STTH v tn bnh nhnM BANgy vo vin Ngy ra vin 1Nguyn Th N.0233301215/7/20121/8/2012 2Nguyn Vn K.120131932/11/201210/11/2012 3Nguyn Th C.121654561/6/201230/6/2012 4Hong Th M.1033328613/9/20125/10/2012 5V Minh H.1055014516/5/201221/5/2012 6Nguyn Tin Ng.1156892215/4/201211/5/2012 7T Minh T.0809132125/4/201210/5/2012 8ng Th E.110258685/8/201213/8/2012 9Nguyn Th Th.074556255/8/20129/8/2012 10Phm Vn Q.1087084010/6/201225/6/2012 11L Th B.0701477529/7/201214/8/2012 12Nguyn Cng L.1081417324/10/20124/11/2012 13Hong Minh T.0826347525/6/20124/7/2012 14i ng U.1200488013/6/201226/6/2012 15Phm Hu C.1009050230/11/20128/12/2012 16Trn Th Kim Th.123456322/9/201212/9/2012 17Phm Th Y.0930343310/5/201218/5/2012 18Nguyn Th Kh.0829956412/6/20122/7/2012 19Nguyn Th B.0801728220/4/201227/4/2012 20Nguyn Vn H.1200789221/3/20129/4/2012 21V Th Th.1109665729/11/201214/12/2012 22Lu Vn S.1208536330/11/201227/12/2012 23Nguyn c K.1008807110/11/201220/11/2012 24Nguyn Thanh B.098569882/9/20125/9/2012 25o Tin Th.0900875429/8/20128/9/2012 26Phm Th H.1098542321/7/201214/8/2012 27 Vn Kh.1005305821/4/20121/5/2012 28m Vn Ng.1244555614/9/201218/9/2012 29Trn Vn M.129823418/8/201227/8/2012 30Nguyn Chu Kh.0563254631/8/20125/9/2012 31Hong Vn Ng.129202441/9/201213/9/2012 32Phm Vn N.1244657824/3/201224/4/2012 33Trn Th Nh.126335247/7/201224/7/2012 34V Nh .0855234515/11/201220/11/2012 35Nguyn Th V.1205041623/5/201230/5/2012 36Nguyn Xun V.120192363/2/201226/2/2012 37Nguyn Vn T.1201356824/3/201218/4/2012 38Trn Vn M.016499588/6/20126/7/2012 39Trn Vn H.1245458627/10/20125/11/2012 40Nguyn Th Ng.0856868113/2/20125/3/2012 41 Th .1103293816/3/201225/3/2012 42Nguyn ng D.6111800623/2/201216/3/2012 43Nguyn Th H.1202121313/2/201221/2/2012 44V nh V.1201900431/1/20125/3/2012 45Nguyn Hu M.048247933/10/20129/10/2012 46Trn Tuyt C.1208696621/3/201231/3/2012 Xc nhn ca phng KHTH