TCNCYHphu tru'dng 71 (6) - 2010
KHANG THUOC KHANG SINH CUA VI KHUAN GAY j
/?BENH DUtfNG HO HAP VA TIEU CHAY 6 TRE EM D U ^ I 5 TUOI j
Nguyin Quynh Hoa\ Nguyin Van Ygn^ \ 'Benh vien Hdu nghi Viet Nam Cuba, ^Sd Y te Ha Noi • j
yVluc tieu: Cap nhat tinh hinh khang thudc khang sinh la rat can thiet de cac thay thudc cd chi djnh i dieu tri hop ly cac benh nhiim khuan. Nghien cdu tien cdu nay dugc tien hanh nham danh gia thi/c • trang khang khang sinh cua cac chung vi khuin phan lap dugc tCf mui hong va phan cda tre dUdi 5 tuoi \ trong cong dong. Doi tuang va phuang phap nghien cdu: 818 tre sau khi ddac theo doi 3 tuan tai cong I dong duac kham sdc khoe va lay benh phim de phan lap S.pneumoniae va E.coli. Mde do nhay cam vdi khang sinh cua cac chdng vi khuan phan lap dugc xac dinh bang phuang phap Etest va khoanh giay khuech tan. Ket qua: phin ldn cac chung vi khuin da de khang vdt tetracyclin, co - trimoxazole, \ erythromycin (70 - 78%) va khang da khang sinh (tren 60%). Ddi vdi viem phoi do phe ciu chi cd amoxicillin va tieu chay do E.coli chi cd ciprofloxacin co dd nhay cam cho phep khuyen cao sd dung : de dieu tri. Ke't luan: can cap bach cd ngay cac can thiep nham nang cao hieu qua si? dung khang sinh \
hdp ly va han che gia tang khang khang sinh. I
Tuf khoa: Streptococcus pneumoniae, Escherichia coli, khang khang sinh, da khang, tre em \ can difa ra chi djnh dieu tri ngay, khdng lam difdc I
L D A T V A N D E
Nhilm khuan difdng hd hap cap tfnh i(NKHHCT) va tieu chay dang la ginh nang benh
tat va tuf vong hing dau d tr^ em dUdi 5 tudi d Viet Nam. Mdt trong nhifng ly do khie'n cho cuoc dau tranh chd'ng lai cac can benh nhigm triing v i n gap ra't nhieu khd khan dd chfnh la tinh trang khang khIng sinh. SU de khIng cua vi khuan gia tang lam Inh hudng de'n hieu life dieu tri cua khang sinh, lam tang so' trifdng hdp tha't bai trdng dieu trj, d i n de'n benh keo dai va tram trpng them, l l m tang chi phi dieu trj va tang ty le chet.
Tai Viet Nam, viec sijf dung khIng sinh khdng hdp ly khi dieu tri viem du'dng hd hl'p va tieu chay d i n den tinh trang khIng thud'c gia tang d 2 chung vi khuan gay benh thudng gap la S..pneumoniae va E.coli [1, 2].
Sd lieu cap nhat ve tinh trang khIng khang
"sinh cua vi khuan tai cdng ddng cd y nghTa rl't Idn cho cac thay thud'c khi phai dUa ra quye't djnh xuf trf vdi benh nhigm khuan. Da sd cIc thay thudc
khIng sinh dd cho tifng benh nhin. Vi vay chung tdi tien hanh nghien cufu vdi muc tieu: Danh gia
thi/c trang khang khang sinh cua cac chung vi khuan phan lap duac tif mui hgng va phan cua tre 6 - 60 thang tudi trong cpng dong. Phan tich mdi lien quan giOa tinh hinh khang khang sinh vdi tinh hinh sd dung khang sinh cua tre.
II. DOI TLfONG VA PHUONG PHAP NGHIEN CLfu
Nghien cufu tie'n cufu, theo ddi 847 tre em 6 - 60 thing tudi trong vdng 4 tuan tai 847 hd gia dinh d huyen Ba Vi, Ha Npi i\J thing 3 de'n thing 7 nam 2007. NgUdi cham sdc tre dUdc phdng van sau mdi tuan bang bp cau hdi cau true de thu thap thdng tin ve sif dung thud'c hang ngay cua tre. Sau 3 tuan theo ddi, tre dUdc mdi de'n Tram Y te xa de kiem tra su'c khde va lay benh pham ngoly mui hpng va phan.
CIc tam bdng ngoay bdnh pham dupc dUng trong tube van chuyen vdi mdi trudng charcoal v l
TCNCYH phu tru'dng 71 (6) - 2010
dUdc chuyen ngay ve khoa Xet nghiem, vien Y hpe lam sang va cac benh nhiet ddi trung Udng.
Vi khuan S. pneumoniae va E.coli dUdc xac dinh va phan lap theo cac quy trinh xet nghidm chuan.
Mufc dp nhay e l m vdi khang sinh cua c I c chung vi khuan phan lap dUdc Xii benh pham se dUdc x l c dinh bang phUdng phap khdanh gil'y khuech t i n (disk difussien) cda hang BIO - RAD Laboratories, Marnes - la - Coquette, France va Etest CLia hang AB bioMerieux plant, Solna, Thuy Dien theo qui chuan ciia Vien tieu chuan ve xet nghiem lam sang (CLSI) [3]. S l u loai k h I n g sinh
da dUdc thuf dp nhay e l m vdi S.pneumoniae la:
b e n z y l p e n i c i l l i n va c e f o t a x i m e (Etest);
erythromycin, co - trimoxazole, tetracycline va ciprofloxacin (disk difussion). S l u loai k h I n g sinh da dUdc thiJ dp nhay d m vdi E.coli la:
ciprofloxacin (Etest); ampicillin, co - trimoxazole, tetracycline, acid nalidixic, cloramphenicol (disk diffusion). Dp nhay e l m dUdc d i n h gia thee hudng d i n cua CLSI - 2007. Dp nhay e l m cua S.pneumoniae vdi phenoxymethylpenicillin, ampicillin va amoxicillin dUdc tinh t o l n tif g i l trj benzylpenicillin MICs thep CLSI [3].
III. KET QUA
1. Dac diem cua ddi tUcfng nghien cu'u va tinh hinh mang vi khuan
Bang 1. Ty le mang phe cau d 818 tre em phan bd theo cac dac diim khac nhau
Ddc diem
Gidi tfnh
Tudi
nhom tre
NO Nam 6 - 2 3 thing 24 - 60 thing
N(%)
373 (46) 445 (54) 367 (45) 451 (55)
So tre mang phe cau (%)
187(50) 234 (53) 203 (55)*
218(48)*
Ddng bang 268 (32) 145 (54)
Khu vUc Trung du 275 (34) 146(53)
Dieu ki§n kinh te
Nhiem khuan dUdng hd ha'p cap
Tieu chly, rdi loan tieu hoa
Suf dung KS trong 3 tuan trUdc tfnh
Mien nui Ngheo Trung binh Khdng cd Cd Khdng cd Cd Khdng Cd Tdng sd
275 (34) 358 (44) 460 (56) 560 (68) 258(32) 773 (94) 45(6) 3.41 (42) 477(58) 818(100)
1 30 (47) 196(55) 225 (49) 265 (47)*
156(61)*
404 (52) 17(38) 183(54) 238 (50) . 421 (52)
* Cd SLf khac biet cd y nghJa thdng ke, ;^ test (p < 0,05).
Cd 818 hd gia dinh ddng y tham gia vao budi kiem tra sufc khod va lay m i u benh pham. Trong sd dd, 421 m i u djch hau hpng phan lap dUdc S.pneumoniae, chiem ty id la 5 2 % . Ta't c l 818 m i u phan deu phan
TCNCYHphu tru'dng 71 (6) - 2010
lap dupc E.coli. Tinh hinh su'c khoe cua trd tai thdi diem lay benh pham va nhdm tre phan lap dUdc S.pneumoniae dUdc md ta d b i n g 1. Cd 3 2 % tre cd cac tridu.chufng NKHHCT va 6 % trd b| tieu c h l y hoac rdi loan tieu hoa, chi cd mdt tre dUdc chan doan viem phdi. Trong vdng 3 tuan trUdc khi lay mau benh pham cd 477/81 8 trd (58%) sil dung k h I n g sinh.
Ty le mang phe cau cao hdn cd y nghTa thdng ke d tre dUdi 24 thang so vdi tre tif 24 - 60 t h i n g va d trd cd trieu chdng NKHHCT so vdi tre khong cd cac trieu chdng nay. Khdng cd sif khac biet cd y nghTa ve mang.
phe cau d tre theo gidi, dieu kien dia ly, kinh te hp gia dinh Va sif dung k h I n g sinh trUdc dd 3 tuan.
2. Tinh hinh khang khang sinh cua S.pneumoniae
Bang 2. So chung va ty le phan tram khang khang sinh trong tdng sd 421 chung S.pneumoniae phan lap dugc Khang sinh
Tetracycline (TET) Benzylpenicillin (PEN G)
Phenoxymethylpenicillin* (PEN V) A m p i c i l l i n * (AMP)
A m o x i c i l l i n * (AMOX) .Cefotaxime (CTX)
Co - trimoxazole (COT) Erythromycin (ERY) Ciprofloxacin (CIP)
ATC code J01AA07 J01CE01 J01CE02 J01CA01 J01CA04 J01DD01 J01EE01 J01FA01 J01MA02
Khang 314 (75)
17(4) 315 (75)
17(4) 17(4) 9 ( 2 ) 329 (78) 294 (70) 119 (28)
Trung gian 44 (10) 136(32)
-
136 (32) 136 (32) 14(3) 4 7 ( 1 1 ) 52 (12) 296 (70)
Nhay cam 63 (15) 268 (64) 106(25) 268 (64) 268 (64) 398 (95) 45(11) 75(18) 6(2) Bang 2 cho thay ket qua nhay cam vdi 9 loai khang sinh cua 421 chung phe cau phan lap difdc. Co 95%, chung (401/421) de khang vdi it nhat mot loai khang sinh va chi cd duy nhat 1 chung nhay cam vdi tat ca cac loai khang sinh. Da sd cac chung vi khuan da khang 1 khang sinh thi khang da khang sinh (252/401),- chiem ty le 60%,. Trong dd kieu each da khang thudng gap nhit la khang dong thdi vdi COT, TET va ERY (200/252).
Ke't qua phan tich da bie'n cho thay khdng cd sU khac biet ve ty le de khang cua c I c chung phan lap tif trd d 2 nhdm tudi va cd dieu kien kinh te khac nhau. C I c chung vi khuan phan lap d c I c trd da dung khang sinh trong vdng 3 tuan trUdc khi lay m i u benh pham cd ty le de khang vdi tat ca cac loai khahg sinh cao hon d tre khdng dung khang sinh trUdc dd.
3. Tinh hinh khang thudc khang sinh cua E.coli
Bang 3. So chung va ty le phan tram khang khang sinh trong tdng sd 818 chung E.coli phan lap dUgc
Khang sinh ATC code Khang Trung gian Nhay cam
Tetracycline (TET) J01AA07 611 (75) 3 ( 0 ) 204 (25)
Chloramphenicol (CHL) J01BA01 326 (40) 10(1) 482(59)
A m p i c i l l i n * * (AMP) J01CA01 533 (65) 5 3 ( 7 ) 232 (28)
Co - trimoxazole (COT) J01EE01 559 (68) 4 ( 1 ) 255 (31)
Ciprofloxacin (CIP) J01MA02 2 ( 0 ) (1) 799 (99)
Acid nalidixic (NAL) J01MB02 220 (27) 2 6 ( 3 ) 572 (70)
TCNCYH phu trddng 71 (6) - 2010
B i n g 3- cho tha'y cac chung E.coli phan lap dUdc cd 4y le de khang khac nhau vdi sau loai khang sinh. Ty le de khang cao nha't la vdi TET (75%), sau dd la vdi COT (68%), AMP (65%), CHL (40%) va NAL (27%). Hau he't c I c chung vi khuan nhay d m vdi CIP. T-/ le chung de khang da khang sinh la 6 1 % (500/818), trong dd kieu c i c h de k h I n g hay gap nhl't la k h I n g ddng thdi vdi TET - AMP - COT. Ke't q u i phan tfch da bie'n cho tha'y cac chung E.coli cd ty le de k h I n g cao hdn d tre dudi 24 t h i n g tudi.
I V . B A N L U A N
Ty le tre mang vi khuan k h I n g d c thudc khang sinh dUdng udng cao dot bien so vdi d c nghien cufu trong nUdc va qudc te [ 4 - 6 ] . Ty le khIng cua S.pneumoniae trong nghien cufu nay vdi COT la 78% va ERY la 7 0 % , cao hdn nhieu sd vdi ty le khang tai huyen Ba Vi nam 1999, trong dd vdi COT I'a 3 2 % va ERY la 2 3 % [1]. Theo b i o d o cua hp gia dinh, 5 8 % tre em dUdc dung khIng sinh trong vdng 3 tuan trUdc khi lay mau benh pham trong khi ty le trd p h i t hien bj viem phdi va cac n h i l m khuan khac la rat tha'p cd the cho thi'y tinh trang sif dung k h I n g sinh bat hdp ly tai huyen Ba vi cd the chfnh la nguyen n h i n g l y ra tinh trang k h I n g k h I n g ^inh d i n g bao dpng hien nay [7]. Theo Hudng d i n xuf trf Idng ghep d c benh thudng gap d tre em cua Bp Y te [8], d c k h I n g sinh dUdc khuyen d o suf d u n g de dieu.
trj viem phdi cho trd em tO 2 - 5 tudi gdm cd:
CO - trimoxazole, amoxycillin hoac erythromycin.
Nghien cufu nay chi ra rang COT va ERY hau nhu khdng cdn t i c dung ddi vdi viem phdi do phe' cau, do dd chung tdi khuyen d o can xem xet lai d c k h I n g sinh dung cho tuyen cd sd thed phac dd xuf trf nay ciia Bd Y te.
Ket q u i khang sinh dd cho tha'y, E.coli da khang vdi d c loai khang sinh thudng dung dieu trj tieu c h l y do n h i l m khuan, trong dd cao nha't la
ty le k h I n g TET (75%), COT (68%) va AMP (65%). D i n g chu y la t^ le de k h I n g vdi NAL, mdt k h I n g sinh thudc nhdm quinolon, la khang sinh dupc lifa chpn trpng dieu trj tieu c h l y do n h i l m khuan nhUng da cd sU gia tang d i n g ke Xy Id de k h I n g (27%). T-y- le khang vdi NAL da tang cao hdn so vdi 7% trong nghien cufu cua Nguyen Thj Tinh nam.2002 va 19% cua N g u y i n Vu Trung nam 2005 [2, 9 ] . Chi cd duy nhl't CIP cd Xy le nhay d m 9 9 % , c h o t h l ' y tfnh hdp ly cua phac dd hudng dan dieu trj tieu c h l y mdi cua Bd Y te khi khuyen d o sO dung CIP de dieu tri ly [10].
V. KET LUAN
Nghien cufu n l y cho thay Xy le de k h I n g rat cao vdi d c k h I n g sinh thUdng dung va da khang khang sinh cCia S.pneumoniae va E.coli. Dd'i vdi nhiem khuan dUdng hd ha'p do phe cau chi cd ampxicillin v l tieu c h l y do E.coli chi cd ciprofloxacin cd dp nhay d m cho phep khuyen d o sif dung de dieu trj. Rat can thiet cd d c can thiep nham nang cao tinh trang sif dung k h I n g sinh hdp ly va han che gia tang k h I n g k h I n g sinh.
TAI LIEU THAiVli KHAO
1. B9 Y t§' (2006). HUdng d i n xiJ trf Idng ghep d c benh thudng gap d trd em. Ha ndi: Bd Y te' Viet nam, W H O , UNICEF.
2. Nguyin Thj Tinh (2002). Vai trd g l y tieu c h l y cua Escherichia coli d tre dUdi 5 tudi va tinh hinh khang sinh cua chung. Luan van thac sy y hpe TrUdng Dai hpe Y Ha N d i .
3. B9 Y te (2009). Tai lieu hUdng d i n xif trf tieu chay d tre em. Ha Ndi: Bp Y te'.
4. Nguyen T.V., Le P.V., Le C.H., &
Weintraub A. (2005). Antibiotic Resistance in Diarrheagenic Escherichia coli and Shigella Strains Isolated from Children in Hanoi, Vietnam.
ANTIMICROBIAL AGENTS A N D CHEMOTHERAPY, Feb, 8 1 6 - 1 9 .
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TCNCYHphu trWdng 71 (6) - 2010
5. CLSI. (2007). Performance Standards for 8. Song J.H., )ung S.I., Ko K.S., et al. (2004). j Antimicrobial Susceptibility Testing; Seventeenth High prevalence of antimicrobial resistance j Informational Supplement. Clinical and Laboratory among clinical Streptococcus pneumoniae isolates j Standards Institute (CLSI). (Vol. 27). Wayne, USA. in Asia (an ANSORP study). Antimicrob Agents {
. . ^ II ," ,~u M T * I Chemother, 48 (6), 2101 - 7. \
6. Larsson M., Kronvall G., Chuc N.T., et al. | (2000). Antibiotic medication and bacterial 9. Adam D. (2002). Global antibiotic |
resistance to antibiotics: a survey of children in a resistance in Streptococcus pneumoniae. J )
Vietnamese community. Trop Med Int Health, 5 Antimicrob Chemother, 50 SuppI, 1 - 5 . | (10), 711 - 2 1 . 10 Hoa N Q , Larsson M , Chuc NTK et al. j
7. Parry C M . , Diep T.S., Wain J., et al. Antibiotics and paediatric acute respiratory \ (2000). Nasal carriage in Vietnamese children of infections i n . rural Vietnam: health - care j Streptococcus pneumoniae resistant to multiple providers' knowledge, practical competence and ; antimicrobial agents. Antimicrob Agents Chemo- reported practice. Trop Med Int Health 2009; 14: j
ther, 44(3), 484 - 8. 1 - 1 0 . 1 Summary j
ANTIBIOTIC RESISTANCE OF RESPIRATORY AND DIARRHEAL BACTERIA AMONG | CHILDREN UNDER FIVE YEARS OLD
Objective: Updated resistance information of bacteria among children is essential to adjust the \ recommendations for empirical treatment of community - acquired pneumonia and diarrhea, which will \ have immense implications for local and global health. This study investigated the prevalence of antibiotic \ resistance in isolated strains of S. pneumoniae and E.coli among children under five in rural Vietnam in i 2 0 0 7 . Methods: 818 children 6 to 60 months were followed up 3 weeks and then were invited for a i clinical examination to collect nasopharyngeal and feece samples for S.pneumoniae and E.coli]
identification. Etest and disk diffusion were used to test antibiotic susceptibility. Results: Very high ' resistance was found to co - trimoxazole, tetracycline, erythromycin (70 - 78%) and multi - drug resistance ] (more than 60%). Conclusions: Resistance to commonly used antibiotics and multidrug - resistance of j S. pneumoniae and E.coli in the area is remarkably high. Amoxicillin and ciprofloxacin are the only ' investigated oral antibiotics that can possibly be used for treatment of community - acquired J pneumococcal infections and bacterial diarrhea. Strategies to promote appropriate prescribing and j dispensing of effective antibiotics should be immediately implemented for the benefit of local and global |
health. ! Keywords: Streptococcus pneumonia, Escherichia coli. Antimicrobial resistance surveillance. Multidrug
resistant. Preschool children
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