Y H p c VIET NAM T H A N G 10 - S6 2/2013
NGHIEN Ciru DAC DIEM DICH TE HOC LAM S A N G BENH N H I I M KHUAN HUYET TAI KHOA TRUYEN NHIEM BENH VIEN NHI TRUNG U'O'NG
Trao Thi Thu Huong*, Pham Nh3t An*, Dang Thi Thu Hang*
TOM TAT
Nhiem khuan huyet (NKH) la mot trong nhu'ng benh truyen nhiem pho bien tai Viet Nam va cac nu'dc dang phat trien vdi ti 1^ benh va ti !e tii vong con cao, De tai du'dc thi/c hien nhSm nghien cifu cSn nguyen NKH va mo ta mpt so dSc diem dich te hpc lam sang va can lam sang cua NKH 6 tre em tel khoa truyen nhiem benh vien Nhi Trung Udng tii thang 01/01/2008 den 31/12/2012. Ket qua cho thay co 195 tre du tieu chuan chan doan nhiem khuan huyet vdi 18 loai vi khuan gay benh du'dc xac djnh. Cac can nguyen du'dc sSp xep theo thu' t i / la:
Staphylococcus aureus {S.aureus) 26.15%, Burkholderia cepacia {B.cepacia) 24.61%, Staphylococcus coagulase negative 9.23%, Klebsiella pneumonia {K.pneumonia) 7.69%, Haemophilus influenzae {H.inHuenzae) 5.12%, S^ptococcus pneumonia {S.pneumoniae) 5.12%, Escherichia coli {Ecoll) 4 . 6 1 % , Pseudomonas aeruginose {P.aeruginose) 4 . 1 % va Salmonella typhi{S.typhi) 4 . 1 % . Tu' khda: nhiem l^huan huyet, hpi chu'ng dap uTig viem he thong'^^
SUMMARY
STUDY SOME CHARACTERISTICS OF CUNICAL EPIDEMIOLOGY OF SEPTICEMIA
I N CHILDREN AT NATIONAL HOSPITAL OF PEDIATRICS
Background: Bacterial bloodstream infections .(BSIs) are a major cause of morbidity and mortality in Vietnam and developing
* B^nh vi4n Nhi Trung uang PMn bi$n khoa lipc: TS.Tran IVIinh Bi^n
countries with many severe complications included: septic shock, acute respiratory distress syndrome^ coagulation dysfunction.
Methods: We retrospectively investigated BSI in children at infectious diseases department at national hospital of pediatrics in Vietnam, from January 1, 2008, to July 3 1 , 2012. The range of bacteria! pathogens and their clinical epidemiology w/ere analyzed.
Results: With 195 diagnosed patient we confirmed about 18 kinds of bacteria, common pathogens included Staphylococcus aureus {S.aureus) 26.15%, Burkholderia cepacia {B.cepacia) 24.61 %, Staphylococcus coagulase negative 9.23%, Klebsiella pneumonia {K.pneumonia) 7.69%, Haemophilus influenzae {H.lnfluenzae) 5.12%, Streptococcus pneumonia {S.pneumoniae) 5.12%, Escherichia coll {E.coll) 4 . 6 1 % , Pseudomonas aeruginose [P.aeruginose) 4 . 1 % vp Salmonella typhi {S.typhi) 4 . 1 % . H.lnfluenzae and S.pneumoniae infection usually associated with meningitis.
Conclusions: BSI is a common problem in Vietnam children attending hospital and associated with significant mortality. Further studies are needed to clarify the epidemiology of neonatal sepsis, the contribution of atypical organisms and the epidemiology of pneumococcal disease before the introduction of vaccine.
Key words: Bacterial bloodstream infections.
Systemic inflammatory response syndrome (SIRS)
L OAT VAN OE
6 nuac ta cung nhu cac nuac dang phat tri^n, benh nhiem khuSn la b?nh dung hang dau trong mo hinh benh tgt. Trong do nhiim
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Hfll NGHI TOAN QUgC Vt CAC B$NH NHI^M TRCING VA HIV/AIDS 6 T R 6 EM NAM 2013
khuin n?ing va s6c nhiem khuan la nguyen
nhan chinh phai nhap vi?n v^ gay tu vong a cac dan vj cham s6c d§c bi?l. Ty I? tir vong do NKN khac nhau, thay d6i tit 30% i&n 50%. 6 My, theo thong ke ciia trung tam kiem sotit b?nh t^t Hoa Ky, hang nSm co khoang 751.000 ca mjc va 215.000 ca lit vong. Tai Brazil, ty 1? mac la 57/1000 va ty 1? tir vong do NKN la 47.3% [7], [8]. a nuac ta, ty 1? tir vong ciia NKN c6n cao. Tai b?nh vi?n Nhi Trung uong ty 1? ttr vong do SNK va NKN khoang tit 40% d^n 80% theo da s6 cac tac gia [1], [2]. Ty I? NKN thay doi theo tuoi, cao nhat cr tre so sinh (5.2/1000) va thap nhat trong s6 5-14 tu6i (0.2/1000)[3].
NKN la tinh trang nhiem triing toan than nang. b|nh khong chi co ty Ie ttr vong cao ma con d^ lai nhieu di chirng nang ne. Kk qua dieu tri phu thuoc vao cSn nguyen gay benh.
kilm soat nhiem khuan, dam bao huyet dong va dieu chinh cac roi loan chuc nang. Tuy nhien. hieu biSt them vS can benh nguy hiJm nay de nang cao hieu qua chan doan, diju tri va du phong hieu qua.
Vi vay chiing toi tien hanh nghien ciru de tai: "IVghien ciru d^c diem dich te hoc lam sang va can lam sang benh n h i l m khuSn huyet t?ii khoa truyen n h i l m Benh Vien nhi Trung l / o n g " nhjm muc tieu:
- Xdc tinh can nguyen NKH tai khoa tniyin nhiim BV Nhi TW tic 1/I/200H din 31/12/2012.
- Mo td mot .10 tac tiem ldm .lang, c(in ldm .icing tren bfnh nhdn NKH
II. BOI TUQNG VA PHU'OfNG PHAP NGHIEN CUTJ 2.1. Doi tu-ffng nghien ciiu: TJt ca nhimg benh nhan dugc chin doan NKH. diSu tri tai khoa truySn nhiem BV Nhi TW tir 1/1/2008 d6n31/12/2012.
Tieu chuan chan doan: Nhthtg benh nhan dugc chan doan NKH dua vao[5]:
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• Hgi chirng dap img viem he thdng (SIRS)
• C6 bang chirng nhiem vi khuan (ciy mau duang tinh)
Tieu chuan chan doan SIRS: Co it nhit 2/4 tieu chuan (trong do 1 trong 2 tieu chuan bat bugc la co bat thuang ve than nhi?t va bach cau mau ngoai vi):
• Than nhiet trung tam >38°5 hoac <36°C
• Nhip tim nhanh, tren 2 do lech chuin (SD) theo tu6i.
• Tan so tha tren 2 SD theo tuoi hoac phai thong khi nhan tao do tinh trang benh cap, khong lien qua den benh nhan than kinh c a hoac thuoc gay me.
• Bach cau mau tang ho^c giam theo tuoi, 2.2. Phu-ong p h a p nghien cihi: Hoi ctru, thu thap so lieu theo mau benh an nghien cmi tCr benh an cua 5 nSm tir 2008-2012.
2.3. Mot so chi tieu nghien ciru 2.3.1, Phdn to sit
D g l : s6t nhe lihiet do 37"5-38°C Do 2: s6t vira. nhiet do >38°C va <39°C Dp 3: s6t cao. nhiet dp >39''C
2.3.2, Phdn to thiiu mduD p i : thieu mau nhe Hemoglobin 90g/l - llOg/1
Do 2: thieu mau vira Hemoglobin >60g/l va <90g/l
Dp 3: thieu mau nang Hemoglobin <60g/l
2.3.3, Phdn lofigan toDo 1: Gan to < 2cm duoi ba suan Dp 2: Gan to 2cm - 4cm dual bo suim Dp 3; Gan to > 4cm dual bcr suan
2.3.4, Phan lofi Idch toD p i : Lach to < 2cm dual bo suon Dp 2: Lach to 2cm-4cm duai ba suon Dp 3: Lach to > 4cm duoi ba suon 2.3.4. Tieu chuSn loai trir;
Benh nhan bi suy giam mien djch (HIV) Benh nhan dual 1 thang tu6i
2.3.5. Xii- ly si lieu theo phuang phap
thong ke sinh hpc: sir dung cac thu^t toan
dua theo phin m6m th6ng ke SPSS 16.0.
Y HOC VigT NAM THANG 10 • s 6 2/2013
III. KET QUA NGHllN Ciru
Trong thcri gian tir 01/01/2008 d«n 31/12/2012 co t6ng s6 195 benh nhan dugc chin doan va ah tri NKH tai khoa Truyte Nhiem BV Nhi Trung uong vai 18 loai vi khuin dugc xac dinh.
3.1. Can nguyen nhiem khuan huylt Bdng I: Cac can nguyen nhiem khuin huyet
Vi khu§n Staphylococcus aureus Burkholderia cepacia Staphylococcus coagulase negative
Klebsiella pneumonia Hemophilus influenzae Streptococcus pneumonia Escherichia coli Pseudomonas aeruginosa Salmonella sp
n(%) 51(26.15) 48(24.61) 18(9.23) 15(7.69) 10(5.12) 10(5.12) 9(4.61)
8(4.1) 8(4.1)
Vi khuin Acinetobacter sp Enterococcus sp Salmonella non typhi Serratia murcescens Sphingomonas paucimohilis Citrohacler.sp
Proteus mirabilis Acinetobacter Iwoffii Burkholderia pseudomallei
n (%) 7(3.59) 4(2.05) 1(0,51) 1(0.51) 1(0.51) 1(0.51) 1(0.51) 1(0.51) 1(0.51) Nh&n xit: Can nguyen nhiem khuan huyet gap nhieu nhat ia S.aureus va B. cepacis chiem 26.15% va 24.61% benh nhan, tiep theo la Staphylococcus coagulase negative 9.23%, K.pneumonia 7.69%. Mot so can nguyen nhu Sphingomonas paucimohilis, Burkholderia pseudomallei... hiem gap;/6i ti le la 0.51%.
3.2. Phan b6 tuoi theo c3n nguyen: Trong 195 benh nhan trong nghien cuu co 95 benh nhan tuoi tir Ithang-ltudi chiem 48.7%, tir Itu6i-5tu6i co 58 benh nhan chiem 29.7% va benh nhan>5tu6i co 37 benh nhan chiem 21.6%.
Bang 2: Can nguyen Vi khuan 5. aureus B.cepacia Staphylococcus coagulase negative Kpneumonia H.lnfluenzae S.pneumonia E. coli P.aeruginosa Salmonella, sp
heo tuoi 1 thang -1 tuoi
n (%) 24(47.1) 25(52.1) 12(66.7) 5(33.3)
9(90) 4(40) 1(11.1)
4(50) 3(37.5)
1 tuoi - 5 tuoi n (%) 11(21.5) 15(31.2) 5(27.8) 5(33.3) 1(10) 6(60) 6(66.6) 1(12.5) 3(37.5)
> 5 tuoi n(%) 16(31.4)
8(16.7) 1(5.5) 5(33.3)
2(22.3) 3(37.5) 2(25)
Nh^nxit: NKH do S.aureus gSp nhieu nhit a lira tu6i ttr>l thang-1 tuoi 47.1%, H.lnfluenzae
cung g}p nhiiu nhit o liia tu6i nay vai 90% benh nhan
H 6 | NGH! TOAN QjfiC V6 CAC BgNH NHI^M TRONG VA HIV/AIDS d TR^ EM NAM 2013
3.3. Bac diem lam sing ciia bfnh nhan Biiu ti I: Tri?u chirng lam sang khi via vien
5,8% 5.8% 5.6
Nhdn xet: Khoang 70% b?nh nhan vao vien vol bieu hien sot cao do 3. chi khoang 3 % bjnh nhan khong co tri$u chiing cua s6t. Benh nhan thuang vao vien vai bieu hien thieu mau mirc dp 1 va 2 va chi khpang 10 % va 5% benh nhan vao vi?n co gan to va lach to dp 3.
3.4. Lien quan giira 6 nhiem khuan dau tien va vi khuan Bdng 3: 6 nhiem khuan dau tien va vi khuan gay benh
Vi khuan S. aureus B. cepacia Staphylococcus coagulase negative K.pneumonia H. influenzae S. pneumonia E. coli P.aeruginosa Tons
Ho hap n(%) 11(21.5) 5(10.4) 2(11.1) 6(40) Uio)
25(12.8)
Tieu hoa n(%) 4(8.3)
6(40)
5(55.5) 15(7.7)
Mang nao n(%)
9(90) 10(100) 2(22.2) 21(10.7)
gay b^nh
Da, mo mem n(%) 40(78.4) 32(66.7) 12(66.6)
4(50) 86(45.2)
long
n(%)
51(100)
41(85.4)
14(77.7)
12(80)
10(100)
10(100)
7(77.7)
4(50)
149(76.40)
Nhdn xit: 78.4% b?nh nhan NKH dp S.aureus co bieu hien nhilm khuin 6 da va mo mem
trong khi do 90% benh nhan nhilm H.infliienzae va 100% benh nhan NKH do S. pneumonia
CO viem mang nao.
Y HOC VI^T NAM THANG 10 - SO 2/2013
3.5. Dac diem can liim sang Bang 4: Oac dierr Hemoglobin(g/l) Bach cau(G/l) Tieu cau(G/l) CRP(mg/I) G0T(UI/1) GPT(UI/1)
CLS cua nhom khoi v BN khoi 100.97±19.92 16.0B3±11.91 316.73±185.96 95.99±85.11
72.17 83.63
a tu vong/xm ve BNTuvong/Xinvl
88.75±17.59 11.87±10.79 226.65±179,04
73,05±90.77 884.71 471.92
p 0.012 0.147 0.05
>0,05 0.001 0.001 Nhdn xet: Lugng hemoglobin, men gan ciia nhom khoi va nhom tit vong/xin vl khac biet co y thong ke vol p<0.05.
3.6. Lien quan gifia vi khuin gay bfnh va soc nhilm khuan Bdng 5: Lien quan gifl-a vi khuin g^y bfnh va soc nhilm khuin
Vi khuin P.aeruginose K.Pneumonia S.Aureus B.cepacia Tong
Co soc 4(50%) 2(15.3%) 5(10.2%) 1(2%) 12(6.3%)
Khong soc 4(50%) 13(84.7%) 44(89.8%) 48(98%) 180(93.7%)
Nh^n xet: Nhom P. aeruginose co ti le soc cao nhat chiem 50% tong so benh nhan nhiem khuan huyet do P.aeruginose
3.7. Ti Ie tir vong va xin ve theo can nguyen Bdng 6: Ti le tu vong va xin ve theo can nguyen
P.aeruginose S.aureus B.cepacia
Staphylococcus coagulase negative Tir vong
n(%) 2(25) 3(5.9) 3(6.25)
0
Xin ve n(%) 1(12.5) 3(5,9) 1(2,05)
1(5,6)
Khoi n(%) 5(62,5) 45(88.2) 44(91.65) 17(94.4) Nh^n xit: Ti le tit vong va xin vl cao nhit a nhom NKH do P. aeruginose 37.5%.
IV. BAN LUAN
Nhilm khuin huyet la mgt benh nhiem triing toan than n?ing vai ti le mic va tu vong con cao mac dii hien nay co rat nhieu Ioai khang sinh thi he mai pho rpng va benh nhan iiigc diiu tri theo khang sinh d6.
Trong nghien curu ctia chiing toi co 195 benh nhan xac djnh co mat ctia vi khuan
trong mau voi nhom tuoi tir 1 thang den I tu6i chiem tl le cao nhit (48.7%) day ciing la lira tufli gap nhieu nhit trong nghien cim cua Al-Zamil (2008)[4[.
Benh nhan nhilm khuin huylt nhap vien
voi nhiiu hinh thai lam sang khac nhau dugc
xac dinh bao gom nhiem khuan da, mo mem
chiim ti le cao nhit 45.2%. khuan ho hap
12.8%, viem mang nao 10.7% ket qua nay
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HOI NGHI T O A N Q U 6 C V £ CAC B E N H N H I § M T R O N G V A HIV/AIDS 6 T R 6 E M N A M 2013
tu'dng tu' nghien cuti cua Al-Zannll tai Saudi Arabia [4] vdi nhiem khuan ho hap 1 0 . 1 % ya viem mang nao 8.2% tuy nhien ket qua nay khong tudng dong vdi nghiSn cihi ciia NImri et al {2001)[6], n h i l m khuan ph6 bien nhat la tieu hoa vdi ti le 40.4%.
Nguyen nhan vl k h u l n thu'dng gSp la S.aureus (51 triidng hdp, 26.15%) thudng lien quan den nhiem triing ngoai da va mo mem vdi 78.4% benh nhan nhap vien vdi trieu chii'ng cua mun nhpt va abces ngoai da, trong nghien ciru ciia Al-Zamll nhiem khuan do S.aureus cDng dirng hang dau (48 trudng hdp, 18.7%)[4], con trong nghien ciru ciia Stoesser et al (2011) d Campuchia vl khuan gSp nhieu nhat la Salmonella typhi (22.8%)[9]. VI khuan g§p cao thir 2 trong nghien diu ciia chung toi la B.cepacia (48 trudng hdp, 24.61%) va nhiJng benh nhan nay cung cd ton thUdng da nhU pliong nude, mun nhpt, loet, chiing toi chUa gap nghien ciJu nao tren the gldl co ti le tUdng t u co le vi B.cepacia la vi khuan ton tai trong moi trudng dat va nUdc va dUdc xem la nguyen nhan ciia nhiem triing benh vien khang thuoc d cac ddn vj cham soc tich cUc, vl khuan nay thudng gay benh tren nhu'ng cd the dac biet n h u benh phoi man tinh, thd may keo dai. Nhiihg benh nhan ciia chiing toi co the bj lay do sir tiep xiic tir da ton thudng vdi vat dung bj nhiem.
Staphylococcus coagulase negative la nguyen nhan gap cao thir 3 trong nghien ciru ciia chung toi (18 trudng hdp 9.23%) day cung la mpt loai vl khuan ton tai d da vi vay nhiihg benh nhan nay gap tdn thUdng da la 66.6%, Can nguyen H.lnfluenzae^h S. pneumoniaqBp 5.12% tong so benh nhi va nhuhg benh nhi nay thudng vao vien vdi bleu hien ciia viem mang nao, dieu nay cung tu'dng dong vdi nghien ciru ciia Al-Zamil [ 4 ] .
P.aeruginose phan lap dude 8 trUdng hdp (4.1%), chiing toi nhan thay khoang 5 0 % trong sd nhilrig benh nhan nay co ton thu'dng phdng nude hoai tir tren da. Day la mgt trong nhOtig dau hieu de nhan biet quan trpng gdp phan dieu trj khang sinh phii hdp. Nhiem P.aeruginose trong nghien citu cua Al-Zamil (2008) [4] la 3.5%.
V. KJT LU«N
Qua nghien cuti 195 benh nhan nhiem khuan
huyet trong thdi g l a n l / 1/2008 den het thang 31/12/2012, Chung toi rut ra mgt so ket luan sau:
" NKH do S.aureusgap t i le cao nhat 26.15%
vdi 78.5% benh nhan cd o nhiem khuan d da va mo mem
• NKH do S. pneumonia va H. influenzae thudng kem viem mang nao mil
• Hdn 7 0 % benh nhan nhap vien trong tinh trang sot cao dp 3 va chi 3 % benh nhan nhap vien khong sot ,
• Nong dp hemoglobin, men gan giii^a nhom khoi va nhdm tir vong/xin ve khac biet cd y nghTa thong ke, ngUdc lai sS lu'dng bach cau, tieu rau, CRP ciia hai nhdm khong cd sU khac biet.
T A I L | | U T H A M K H A O
1. Do Thj Minh C3m (2004), 'Nghien culi rdi ban cam mau - dong mau cf tre bi nhiim khuan huy^
tai benh vien Nhi trung uangf, Lu|n an Sen sy Y hoc, chuyen nganh Huyet hoc - Truyen mau.
2. Tr'an Minh Dien, Lu'dng Thj San (2003), 'Nhan xet tinh hinh nhiem khuan huyet trong 2 nam 1997-1998 tai khoa hoi s&c cap OJV benh vien Ntii tnjng Udng', 1 hgc thuc hanh so 462,116-119, 3. Tran Minh Oien {liitlQ), 'Nghien ciiU ket qua dieu
tri va mot sd yeu td tien Iudng hi' vong tmng shock nhiem khuan tre enf', Luan an tien sy Y hoc.
4. Al-Zamil (2008), Bacteremia In children at the University Hospital in Riyadh, Saudi Arabia. World 1 Pediatr 4(2): 118-22.
5. Goldstein B, Giioir B, Randolph A(2O05), International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatncs .Pediatr Crit Care Med.
2005 J a n ; 6(l):2-8.
6. Nimri LF, Rawashdeh M, Meqdam MM.
Bacteremia in children: etiologic agents, fixal sites, and risk factors. J Trop Pediatr 2001; 47: 356-360.
7. Parker Robert I , Hazelzet ] a n A. (2008), Coagulation Issues in the PICU, Roger's Textbook of Pediatric Intensive Care, 4th Edition, 103.
8. Sacha Zeerleder, C. Erik Hack, Walter A.
Wulllemln. (2005), Disseminated Intravascular Coagulation In Sepsis, Chest, 128, 2864-2875 9. Stoesser et al(2013). Pediahic bloodstream
infections in Cambodia, 2007 to 2011. Pediatr Infect Dis J; 32(7): 272-6.
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