HQI NGHI TOAN QUdC Vg CAC B$NH NH|£M TRONG VA HIV/AIDS 6 TR£ EM NAM 2013
NGHIEN CU'U CAC CAN NGUYEN GAY VIEM PHOI TRE EM VA TINH KHANG KHANG SINH COA VI KHUAN GAY
VIEM P H S I rnt EM TIT i THANG DEN I 5 TUOI
0^0 Minh Tuan*, Dang Thj Thu H5ng**, Nguyin Thi Ngflc Tran*, Vfi Thj Huyen**, Truffng Viet Nga*, Vu Thanh Binh*, Hoang Thi Thu HSng*, TrSn Thj Sinh***
T 6 M TAT
Nghien cffu 1876 benh nhi viem phoi vao khoa ho hap benh vien Nhi TU" tff thang 5 nam 2012 den thang 5 nam 2013 cho thay cSn nguyen chu yeu gay viem phoi tre em dffdi 15 tuoi la virus (59,7%), vi khuan (36,14%), nam va ky sinh trung (4,16%), Trong do, virus RSV van chiem da sd (61,56%), tiep theo la cum A, Rhlnovirus, Adenovirus, cum B, Nhdm vi khuan, phe cau van la nguyen nhan hang dau (32,50%), tiep theo la H.lnfluenza (22,17%). Cac vi khuan Gram am nhff E.Coll, P.aeruginosa, K.pneumonia cd xu hffdng tang khoang 6-7%. Cac khang sinh cdn nhay cam tdt vdi vi khuan la Quinolon va Vancomycin, sau la Carbapenem va Macrolid.
Nhdm Betalactam va Cephalosporin bj vi khuan de khang cao.
n/'AAda.'Viem phoi, virus, vi khuan, khang sinh, benh nhi.
SUMMARY
Research causes of pneumonia and antibiotic resistance of bacteria
causing pneumonia in children from 1 month to 15 years We study 1876 patients with pneumonia in the Respiratory department of National hospital of pediatric from May 2012 to May 2013. The
* Khoa Ho hap
** Khoa Visinh
* * * Khoa Sinh hoc phan tir
Phan hi^n klioa hifc: TS. Tr^n Thanh Tu
major causes of pneumonia In children under the age of 15 are virus (59.7%), bacteria (36.14%), fungi and parasites (4.16%). In particular, RSV is still majority (61.56%), followed by Influenza A, Rhlnovirus, Adenovirus, Influenza B. Bacteria, S.pneumonia is the leading cause (32.50%), followed by H.lnfluenza (22.17%). The Gram- negative bacteria such as E.coll, P.aeruginosa, K.pneumonia tend to increase by 6-7%. The antibiotic susceptible bacteria is good with Quinolone and Vancomycin, followed by Carbapenems and Macrolides. Group Betalactam and Cephalosporin are resisted highly by bacteria.
I. OAT VAN OE
Hang nSm, sd tre mac viem phdi van chiem ty le cao nhat trong cac benh ly nhiem trung tre em, d nude ta cung nhu tren the gidi. Rieng a benh vien nhi TU'. sd benh nhan viem phdi nang phai nhap vien cung kha cao, chua cd xu huoTig thuyen giam.
Viec cap nhat tinh hinh c5n nguyen gay viem phoi d tre em cung nhu tinh trang khang khang sinh cffa viem phoi la rat can X\\\k, giup cho viec lira chon phuang phap dieu tri dac biet la khang sinh doi vdi tac nhan vi khuan.
Sy cap thiet va tinh phd biSn cua de tai nghien cffu nay dugfc th^ hien vai hai muc tieu sau:
14
Y HQC VigT NAM THANG 10 - SO 2/2Q13
Tim hieu cac can nguyen vi sinh gay viem phdi tre em vao khoa Hd h4p benh vien Nhi TU"tunam 2012-2013.
cap nhat tinh tr^g khang khang sinh cua cac vi khuan gay viem phdi d tre em.
11.001 Tl/QNG VA PHirONG PHAP NGHIEN COU 2.L Doi tiTQiig: Bao gdm cac benh nhan dugc chan doan viem phdi dieu trj tai khoa Hd h^p benh vien Nhi TlT tff thang 5/2012 din thang 5/2013.
2.2. Phiromg ph^p nghien ciru 2.2.1. Phudng phdp nghiin cAu: md ta - hdicuxi
2.2.2, Tieu chuan l^a clign benh nhan:
- B?nh nhi dugc chSn doan xac dinh viem phdi theo tieu chuin cua WHO-2006 [7]
- Tre tff 1 thang den 15 tudi
- Thdi gian nghien cffu tff thang 5 nam 2012 den thang 5 nam 2013
- Benh pham nghien cffu can nguyen vi sinh:
cac loai dich tiet dudng hd hap (dich ty hau hoac djch rffa phe quan phe nang hoac dich ndi khi quan)
- Thdi diem lay benh pham: ngay dau tien vao vien.
2.3. Cac thong so nghien cthi: cac c^n nguyen gay viem phdi (virus, vi khuan, vi khuan khdng dien hinh, nam, ky sinh trung), mffc do nhay va khang khang sinh cua vi khuan
2.4. Xu- Iy so lieu: theo chuong trinh SPSS 16.0
111. KET QUA
3.L Cac nguyen nhan gay viem phoi dugc tim thay tgi khoa Ho hap benh vien Nhi TU" tir thang 5/2012 den thang 5/2013
Hinh 1: Nguyen nhan gay viem phdi d benh nhi 4.16% 0.27%
H Vi khuan
• Virus D Mycoplasma DNlm
• Ki sinh trung
Tong s6 cac benh nhan viem phoi tim duac nguyen nhan la 1H76 benh nhan. Trong do. ty le viem phdi do virus la cao nhat 59,70%, dung thu 2 la vi khuan 31,9H%, .iau do Id Mycoplasma 4,16%, ndm 3,89%. ky sinh trung 0.27%,.
3.2. Can nguySn virus gay viSm phoi
3.2.1. So lirong benh nhi vi€m phoi nhiSm virus theo cac thang Hinh 2: Phan bd sd lugng benh nhi viem phdi do virus theo thang
H6| NGHI TOAN QUgC yg CAC BgNH NHigM TRtiNG VA HIWAIDS 6 TRS EM NAM 2013
Benh nhan
i l m
so 77
» iw M • §|.n m • m
Tliiri gian
Trong 13 thang, s6 tuong b^nh nhi viem phoi phat hifn duac nguyen nhan virus la 1120 trucmg hap. So luang henh nhi viem phoi virus tang cao a thdng 5.6:1.2 va 4.
3.2.2. Ty /f cac loai virus gay viSmphoi Hinh 3: Ty le cac loai virus gay viem phoi o benh nhi
2.50% .«»
j DRSV
• Cum A D Rhlnovirus D Adenovirus
• Cum B
Trong viem phoi do virus, ty le nhiem RSV Id cao nhat 61,56%. sau do Id cum A 14,42%, Rhlnovirus 13.81%. Adenovirus 7,71%, it nhdt Id cum B 2.50%.
3.3. Viem phoi do vi khuan
Bang 1: Ty 1? phan lap dugc vi khuan d cac benh pham dich tiet duong hd hap B?nh pham
Dich ty hau Dich rira phe quan Djch npi Ithi quan Tong
So lu{;mg mau 3080
240 43 3363
Mau duong tinh 551
34 15 600
Ti le % 21,79 14,17 27,90 17,84 .
Ty le phan Icip duac vi khuan a dich noi khi quan Id cao nhdt 27,90%. thdp han Id dich ty hdu 21,79% vd dich rua phe quan phe nang Id 14.17%,
Y HOC V I I T NAM T H A N G 10 - SO 2/2013
Bang 2: Phan Ioai vi khuan gay benh theo benh pham Vi khu3n gay benh
Achromobacter sp.
Achromobacter xylosoxidans ss.
Xylosoxidans
Acinetobacter baumannii Acinetobacter Iwoffii Acinetobacter sp.
Burkholderia cepacia Candida albicans Candida sp.
Citrobacter braakii
Elizabethkingia meningosepticum Enterobacter cloacae Enterobacter sp.
Escherichia coli Haemophilus influenzae Klebsiella pneumoniae ,5.y.
Klebsiella .ip.
Moraxella (Branh.) catarrhalis Proteus mirabilis
Pseudomonas aeruginosa Pseudomonas putida
Staphylococcus aureus ss. Aureus Staphylococcus hominis ss. hominis Stenotrophomonas mallophilia Streptococcus mitis Streptococcus pneumoniae Streptococcus viridans, alpha-hem.
So benh pham
1 3 6 1 6 1 64 9 1 2 3 3 45 133
15 24 6 1 41 1 33 1 1 1 195
3 600
Dich rua PQPN
1 8 6
2 I 3 1
5 1
1 5 34
Dich ty hau
1 2 3 1 5 1 55 3 2 3 3 41 132
12 22 6 1 34 1 32 1 1 187
2 551
Dich ngi khi quan
1 3
1 1
2
1
2
3 1 15 Vi khuan thuang ggp nhdt let phe cau
(S.pneumoniae). dutmg tinh 195 trudng hap (tuang ting v6i 32.50%). Biing thu 2 Id H.lnfluenza, duong tinh 133 trudng hap (tuang ting vai 22.17%). E. Coli dung hang thii 3. duong tinh 45 truang hap (7.50%).
Ngoai ra nhung vi khuan gay viem phoi nang nhu Pseudomonas aeruginosa.
Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter, Burkholderia cepacia duang linh vai ty le cao 129 truang hap (21,50%)
HOI NGHI TOAN QU6C Vg CAC B^NH NHI^M TRONG VA HIV/AIDS 6 T R 6 EM NAM 2013
Bang 3: Khang sinh d6 cua Ph6 cat Khang sinh
Penicillin G Oxacillin Cefotaxime Imipenem Ofloxacin Trimethoprim/
Sulfamethoxazole Clindamycin Erythromycin Vancomycin Chloramphenicol
SL 198 198 198 198 198 198 198 198 198 198 198 198
%R 64.2 100 21,3 21,8 14,4 1,3 91,4 88,3 97,7 98,4 0 25
%I 2,1 0 12,2 18,3 70,6 2,5 6,1 1,2 0 0 0 0
33,7
%s
0 66,5 59,9 15 96,2
2,5 10,5 2,3 1,6 100 75 Phi ciiu nhay cam vai Vancomycin cao (100%). Ofloxacin 96,2%,. Phe cdu khdng nhom Marcrolid vai ty le cao (vai Azithromycin la 97.7%,. v&i Erythromycin let 9H.4%). Phi ck khang vai nham Oxacilin (100%), Penicillin U (64,2%). Phi cdu hit ddu khdng vai Cephalosporin the he HI (>20%)
Bang 4: Khang sinh do cua H.lnfluenza Khang sinh
Ampicillin
Amoxicillin/Clavulanic acid Piperacillin/Tazobactam Cefuroxime Ceftazidime Ceftriaxone Cefotaxime Cefepime Imipenem Meropenem Ciprofloxacin
Trimethoprim/Sulfamethoxazole Azithromycin
Chloramphenicol
SL 135 135 135 135 135 135 135 135 135 135 135 135 135 135
%R 71,1 35.6 6,7 70.4 66,7 44,4 48.1 84,4 1,5 5.2 2,2 95,6
7,4 32,6
%1 13,3 0 0 9,6
0 0 0 0 0 0 0 0,7
0 5,9
%S 15,6 64,4 93,3 20 33,3 55,6 51,9 15,6 98,5 94,8 97,8 3,7 92,6 61,5
H.lnfluenza cdn nhay cam cao vai Azithromycin 92,6%. Imipenem 98.5%,, Meropenem 94.8%.
Ciprofloxacin 97.8%, Piperacillin/Tazobactam 93.3%. H.lnfluenza khdng vai cdc khdng sinh nhom Cephalosporin the he J, 11, III, IV khd cao (> 44%,). nhom Ampicillin (71.1%)
Y HOC Vier NAM T H A N G 10 - SO 2/2013
Bang 5; Khang sinh do ciia E.Coli Khang sinh ESBL
Ampicillin
Amoxicillin/Clavulanic acid Ampicillin/Sulbactam Ticarcillin/Clavulanic acid Piperacillin/Tazobactam Cephalothin Cefoperazone Cefuroxime Ceftazidime Ceftriaxone Cefotaxime Cefepime Impienem Meropenem Amikacin Gentamicin Tobramycin Ciprofloxacin
Trimethoprim/Sulfamethoxazole Nitrofurantoin
Chloramphenicol
SL 49 49 49 49 49 49 49 49 49 49 49 49 49 49 49 49 49 49 49 49 49 49
%R 86,4 97,7 38,8 85,3 59 25,6 95,9 95,9 95,9 77,1 97,7 97,7 70,8 0 0 31,2 68,8 52,1 29,2 77,1 2.5 55,1
%1 0 0 34,7
4.9 23,1
9,3 0 0 0 0 0 0 2,1
0 0 0 0 25 0 0 17.5
0
%S 13,6 2,3 26,5 9,8 17,9 65,1 4,1 4,1 4,1 22,9
2,3 2,3 27,1
100 100 68,8 31,2 22,9 70,8 22,9 80 44,9 E.Coli niigy cam rat cao vai nhom Imipenem vd Meronem (100%). nhay cam cao vai Ciprofloxacin (70,8%). E.Coli khang rat cao vai cdc khdng sinh nhom Ampicillin (>85%), Cephalosporin cdc the he (> 70%o). Dac biet, vi khuan nhom Gram dm nhu E.Coli vd Klebsiella co ty le khdng men ESBL cao (86,4%)
IV. BAN LU$N
4.1. Nguyfin nhan gay viem phoi K6t qua nghien cmi cho thay so lugng benh nhi nhilm virus cao hem hSn so voi cac nguyen nhan khac (gin 60%). Ket qua nay phu hgp vcd nghien cuu cua Olli Ruskanen nam 2011 [6]. Day la ykvt t6 cc so cho qua trinh di6u tri cho benh nhi ii tranh l^m dyng khang sinh. Clin phai chii y dSn dieu tri trieu chung, cham soc va nang cao the tr^ng cho benh nhi.
GSn day, vi khuSn khong diSn hinh cung dugc chii y nhieu hon, dac biet la
Mycoplasma thuang gay viem phoi kem theo sot cao 6 tre Ion. Goi y nay giiip cac nha lam sang quan tam va lira chpn khang sinh thich hgp cho benh nhi.
Benh nhi viem phoi keo dai, dac biet co nam trong mieng hpng can dugc chii y diSu tri thuoc chong nam kip thoi.
So lugng benh nhi dirge phat hien ky sinh triing khong nhiju, nhung m6i trucmg hop la cac ca lam^ sang kho va phiic tap trong chan doan ya diSu tri. Cac nha lam sang nen chu y toi van de ky sinh triing, dac biet a nhihig benh nhi co ty le bach cau ua axit tang cao.
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HOl NGH! TOAN Q U 6 C Mt CAC B^NH NHI§M TRONG V A HIV/AIDS 6 TR^ EM N A M 2013
Xet nghiem ELISA mau rat gia tri trong chan doan. c a n dieu tri kjp thdi, t r ^ h ky sinh trung di chuyen gay ton thuong sang c a quan dich khde.
4.2. Viem phoi do virus d* b9nh nhi Cac thang giao mua sd lug-ng b?nh nhi mSc viem phoi do virus tSng cao han so vdi cac thang thdi tiet on djnh.
Virus thudng g^p nhat la RSV. cffm A, thap ban la Rhlnovirus. Adenovirus, cum B.
Ket qua nay phii hgp vdi mgt nghien cffu djch te ve nhiem khuan ho hap cSp d 309 tre em nhgp vi?n t^i thanh pho Ho Chi Minh nam 2004-2008 [4],
4.3. Viem phoi do vi khuan d* b$nh nhi Theo bang 1. ty 1? cay duong tinh d dich ngi khi quan I^ cao nhat 27.90%, dich ty hau Ia"21.79%. djch rffa ph^ quan la 14!l7%'. Ty le nay phu hgp vai nghien cffu trudc cua tac gia Dao Minh Tuan va Le Thi Hoa tai khoa Hd hip benh vien Nhi TU" nam 2 0 1 1 [ i ], [ 1 ].
Bang 2 cho^ thdy vi khuSn hay gap nhk vh\ la pha ciu (32,5%) va H.lnfluenza (22,17%). Ket qua nghien cuu nay phCi hgp vdi cac nghien cffu cffa cac tac gia trudc nhu Garcia Ramos nam 1991 [5], Tran Do Hung nam 2010 [3]. Cac vi khuan gay viem phdi nang dang cd xu hirdng tang dang bao ddng.
Dac biet khi van de khang khang sinh dang gia tang nhu hien nay.
4.4. Khang sinh do ciia cac loai vi khuan hay gap
Nhin chung, cac vi khuan cdn nhay r4t cao vdi nhdm Quinolon. Tuy nhien, nhdm Quinolon chua dugc khuyen cao sff dyng rong rSi cho tre em_ vi tac dyng phu cua nhdm nay. Ngoai ra, phd cau nhay cam 100% vdi Vancomycin. H.lnfluenza nhay cam cao vdi nhdm Macrolid, Carbapenem.
Ty Ie vi khuan khang khang sinh nhdm Cephalosporin ngay cang cao. Vi khuSn khang ESBL. Day la nhffng thach thffc dat ra cho cac nha Iam sang.
V. KET LUJ^N
Viem phdi tren benh nhi dieu tri tai khoa Hd hdp benh vien Nhi TU" tff thang 5/2012
20
ddn thang 5/2013 thudng gap nhat la do virus va vi khuan.
Sd lugng benh nhan viem phdi virus thuang gia tang theo mua. Virus thudng gap nhil la RSV va cum A.
Vi khuan hay gSp gay viem phdi cua b§nh nhi la phe cau va H.influenza.
Cac vi khuan con nhay cao vai nhdm Quinolon. Phe cau nhay cam 100% vdi Vancomycin. H.lnfluenza nh$y cam Cao vdi nhdm Macrolid. Carbapenem. Cac vi khuan cd xu hudng khang khang sinh nhdm Beta lactam va Cephalosporin.
T A I L I I U THAM KHAO
1. Dao iVIinh Tuan va cs (2012). Nghien ciru cfin nguyen va mffc dp khang khang sinh ciia vi khuan gay viem phdi tre em tff 1 thang din 5 tudi. T^p chi Y hgc Vi^t Nam, tap 397, tr.2l6-2i.
2. Dao Minh Tuan va cs (2010). Nghiem cffu nguyen nhan. djch te hgc lam sang viem phoi nang d tre em dudi 5 tuoi tgi khoa Ho hSp Benh vien Nhi Trung uong nam 2008. Tap chi Y hoc thirc hanh. tap 666. tr.102-03.
3. Tran Do Hung va cs (2010). Nghien cihi cac vi khuan va mffc dg de khang khang sinh d tre em bi viem phdi nam dieu tri t^i khoa Hd hap Benh vien Nhi Dong Can Tho. Tap chi Y hgc thuc hanh.
4. Do AH, van Doom HR, Nghiem MN, Bryant J E , Hoang TH, et al (2011). Viral etiologies of acute respiratory infection among hospitalized Vietnamese children in Ho Chi Minh City (2004-2008). PloS One.
Mar24 6(3):el8176.
5. Garcia Ramos E, Pizarro Suarez and et al (1991). Epidemiologic and etiologic study of acute respiratory infections in children under 5 years of age. Rev Latinoam Microbiol.
Apr-Sep 33(2-3), pp.109-19.
6. Olli Ruuskanen, Elina Lahti, Lance C Jenning, David R Murdoch (2011), viral pneumonia. Lancet; 377:1264-75 7. WHO (2006). The management of acute
respiratory infection in children, pp.l-77.
