Y HOC VIET NAM T H A N G 10 - SO 2/2013
NGHIEN CU'U DAC DIEM LAM S A N G , CAN LAM S A N G V A TINH NHAY CAM V a i KHANG SINK CUA VI KHUAN TRONG VIEM PHOI THUY 6* TRfi EM
LS Thi Hong Hanh*, Nguyen Thj Ngoc Tran*, Dang Mai Lifin*, Vu Thanh Binh*, Nguyen Thanh Binh*, Nguyin D3ng Quy^t*
TOM TAT
Nghien cmi 120 benh nhi viem ph6i thuy (VPT) vao khoa Ho hAp bfnh vien Nhi TLT tir thang 8 nam 2012 din hk thang 7 nam 2013 cho thay VPT chu yeu gap dr tre Ion, nam nhieu hon nG. TriSu chu'ng lam sang thucmg g^p la ho (100%), s6t (94,20%). 56,70%
trirong hgp khong nghe thay ran a phoi. VPT thuang do Mycoplasma (36.67%), ph6 cSu (18,33%) va H.lnfluenza (7,5%). 1 trircmg hap virus cum A ducmg tinh. Cac vi khuan con nhay cao voi nhom Quinolon. Phe cau nh^y cam 100% vai Vancomycin, H. influenza nhay cam cao vai nhom Azithromycin va Carbapenem.
Tk khoa: Viem phoi thuy, lam sang, can lam sang, Mycoplasma^ phe cau, H.lnfluenza, khang sinh, benh nhi.
SUMMARY
RESEARCH CLINICAL CHARACTERISTICS, LABORATORY TESTS AND ANTIBIOTIC SUSCEPTIBILITY OF BACTERIA I N THE LOBAR PNEUMONIA I CHILDREN We study 120 patients with lobar pneumonia (LP) in the Respiratory department of National hospital of Pediatrics from August 2012 to the end of July 2013. The most cases are old children, males are more than females. The common clinical symptoms are cough (100%) and fever (94.20%). 56.70% of cases are not heard rales in the both lungs. LP is usually
* B4nh vien Nhi Trung irang Phdn bi^n khoa hgc: TS. Trk Thanh Tii
caused by Mycoplasma {36.S7°/o), pneumococcus (18.33%) and H.lnfluenza (7.5%). 1 case with Influenza A virus. These bacteria are high sensitive with the Quinolone group.
Pneumococcal susceptibility with Vancomycin is 100%, H.induenza is high sensitive with Azithromycin and Carbapenems.
\. © A T VAN OE
Viem phoi thuy la mot benh cap tinh va dien bien ram ro. Nguyen nhan gay benh co dien la phe cau. Benh thuang gay ra nhihig bien chimg nang nhu hoai tu, ap xe phoi, tran dich, tran khi mang phoi, viem mu mang phoi, nhiem khuan huyet, soc nhiem khuan hay tir vong. Viec dieu tri gap nhieu kho khan do benh dugc chan doan muon, do vi khuan giam nhay cam vai khang sinh hoac do nguyen nhan gay benh la nhung vi khuan khac.
Vi vay, de tai nay la van de can thiet, co y nghTa thuc tien nham chan doan som, dieu tn dung va kip thai, han che nhung bien chung nang do benh gay ra.
Muc tieu:
• Nghien cuu dac diem lam sang, can lam sang cua viem phoi thiiy a tre em.
• Nghien cuu can nguyen gay benh, tinh nhay cam voi khang sinh cua vi khu4n da phan lap dugc a benh nhi viem ph6i thuy.
II. 0 0 1 TUQWG, 0!A OI^M VA THOI GIAN NGHIEN CCru
2.1. Doi tirgng nghiSn ciiu
HOl NGH! TOAN QUOC v£ CAC BgNH NHI^M TRONG V A HIWAIDS 6 TRg EM NAM 2013
Bao g6m 120 b?nh nhi ttr 2 den 15 tuoi, dugc chSn doan la viem phoi thuy vao dieu tri tai khoa ho hap benh vi?n Nhi TU' tij' thang 8-2012 din hk thang 7-2013.
2.2. Tieu chuan lu-a ch^n doi tu(flig nghien cuu:
- Benh nhdn tir 2 den 15 tuoi.
- B$nh nhdn duac chdn dodn xdc dmh viem phoi thuy theo tieu chudn ciia to chirc y le the mi-
2.2.1, Tiiu chudn chdn dodn viem phoi tliuy:
Theo tieu chuan ciia to chuc y te the giai (WHO 2006) [7]:
- Bieu hi$n tinh trqng nhiem trung todn than:
sol hodc hg nhi$l do
- Cd ton thuang thuc the tai phoi hodc khong ' X-quang cd hinh anh viem phoi thuy
2.2.2. Tieu chudn loai tru:
Tre du6i 2 tuoi
- Gia dinh b?nh nhi khong dong y tham gia nghien ciru
2.3. Dia diem nghien ciru
- Nghien curu lam sang dugc thuc hien tai khoa Ho hap Benh vien Nhi TU"
- Nghien curu can lam sang dugc thuc hien tai khoa Sinh hoa, khoa Huyet hgc, khoa Vi sinh, phong Sinh hgc phan tur. khoa Chan doan hinh anh - Benh vien Nhi TU".
2.4. Thoi gian nghien cihi: Nghien cuu dugc tien hanh tir thang 8/2012 den het thang 7/2013
2.5. Cac thong so nghien ciru: tuoi, gicri.
trieu chung lam sang, trieu chOmg c|n lam sang, miic dg nhay va khang khang sinh cua vi khuan gay viem phoi thiiy
2.6. Xir ly so lifu: theo chuang trinh SPSS 16.0
III. KET QUA
3.1. Mot so dac diem chung ve djch te hoc benh nhan viem phoi thuy 3.1.1. Tuoi mac benh
Bang I: Phan bo benh nhi viem phoi thuy theo lira tuoi Tuoi
2 - 5 tuoi
> 5 tuoi Tong so
So benh nhi 70 50 120
Ty 1? % 58.3%
41.7%
100%
Tuoi mac henh trung hinh cua bfnh nhi VPT Id 4,7 t 2,9 tudi, Tudi Idn nhdt Id 13 tudi Tudi nho nhdt la 2 tudi Trong do, tudi mdc hfnh trung hinh cua henh nhi nhiim Mycoplasma Id 6,1 ±3,6 tuoi, cao han so vai hi'nh nhi nhiim phi cdu vd H.Influenza (4.0 ±2.2 vd 3,3 ± 1,4 tudi)
3.1.2. Phan bi bfnh nhi theo gidi
Hinh I: Phan bo b$nh nhi viem phoi thuy theo gidi tinh
DNam
• NO'
Benh nhi nam (71,70%) nhiiu km so vol benh nhi nu (2H,30%) vm ty le henh nhi nam/nit = 2.5/1 54
Y Hpc V|6T NAM THANG 10 - S 6 2/2013
3.1.3 Phdn bd benh nhi theo Jia du:
Hinh 2; Phan bo benh nhi viem ph6i thuy theo dja du
D nong thon
• thanh thj
Ty 14 benh nhi din til thanh thj (58,30%) cao han so vdi benh nhi din tu nong thdn (41,70%).
73.3% benh nhi dd duac diiu tri truac khi nhap vien nhung khong khdi. chi 26.7% chua diiu tri gi. Trong so cdc benh nhi da diiu trj trudc khi vao vi(n, da sii diiu tri tai nhd 69.3%; dieu trj tai ca sa y ti 30.7%
3.2. Die diim lam sing, c^n lam sing 3.2.1. Bgc diim ISm sdng viem phdi thuy
Hinh 3: Trieu chimg co nang viem ph6i thuy
j • Tri^u chiyng ISms^ng
Gram thdng khf 1 ben phoi
0% lord 20% 30% 40% 50% 60% 70% 80% 90% 100%
Trifu chung thudng gap nhdt cda viem phoi thiiy la ho (100%) vd .ml (94.20%). Ho khan 13,3%, ho cd ddm 86.7%. Sau do la ran a phoi (43,30%,). gidm thdng khi (25%). khd thd (8,3%), hoi chiing ba gidm (5.8%), dau ngifc (3.3%)
55.
HOl NGH! TOAN QUtSc Vg CAC BgNH NH|6M TRONG VA HIV/AIDS 6 TRS EM NAM 2013
Bang 2: Moi lien quan gi
Ho Sot Kho tho Dau ngtrc
Giam th6ng khi phoi 1 ben Ran
Ran^m Ran phe qu^n
ua vi khuan va tri?u chimg lam sang Mycoplasma
100%
90.7 % 4.7 % 2.3 % 23.3 % 32.6 % 85.7 % 14.3%
Phe cau 100%
95.5 % 0 4.5 % 31.8%
45.5 % 90%
14.3 %
H.lnfluenza 100%
100%
0 0 0 77.8 % ^ 85.7 % 14.3 % 7r/^H chung lam sang kho phdn hi$t viem phdi thuy do tieng nguyen nhdn. Viem phdi thiiy do H.lnfluenza thuang nghe thdy ran nhieu han so vai cdc viem phoi thuy do nguyen nhdn khde.
3.2.2. D^c diem can lam sdng ciia viem phoi thuy Bdng 3: Moi lien quan giira vi khuan va can lam sang
~~~- . . . ^ N g u y e n n h a n
C?n Iam s i n g -..., Xquang dien hinh {%)
Tran djch mang phoi (%) Bach c k (G/L) Bach cau trung tinh(%) CRP (mg/dL)
Mycoplasma
25.6 20.9 10.2 ±6.4 55.6 ±13.5 49.1 ±58.7
Phe cau
22.7 9.1 16.5 ±9.5 64.7 ±12.3 31.5±45.5
H.lnfluenza
33.3 0 14.3 ±6.7 51.8±12.8 57.4 ±58.7
Chung
25 13.3 13.9 ± 8 . 6 57.3 ±15.3 54.7 ±67.2 X-quang phoi dien hinh la hinh anh ton
thucmg khu tru toan bo 1 h a y nhieu thuy phoi, chiem 2 5 % a benh nhan V P T noi chung. Cac benh nhi khac hinh a n h X-quang CO ton thuoTig tap trung thanh d a m k h 6 n g ' dien hinh.
Tran dich m a n g phoi g a p a 1 3 , 3 % cac trucmg hgp. Tran dich m a n g phoi k e m theo gap nhieu 6 benh nhi nhiem Mycoplasma hem so vai b?nh nhi nhiem P h e c i u . Trong nghien
cuu nay. chiing toi k h o n g g$p truang hgp V P T do H.lnfluenza c o tran dich m a n g phoi.
Gia tri trung binh ciia b^ch c a u trong V P T la 13.9 ± 8.6 (G/L). S6 l u g n g bach c^u trong V P T d o Mycoplasma co gia tri thap hon so P h e cau va H. Influenza.
Ty le bach cau trung tinh co gia tri 57.3 ± 15.3(%)
Trong V P T , C R P t h u a n g t&ig cao, gia tri trung binh la 54,7 m g / d l .
3,2,3. Nguyen nitdn gay b^nh
Hinh 4: C a c nguyen nhan gay b?nh viem phoi thuy -7.50%
I^ Mycoplasma
• Ph^cau a HI
• cijmA
• khong ro
Y HOC VI^T NAM THANG 10 - SO 2/2013
Nguyin nhdn gdy VPT chu yeu Id do Mi khudn khong dien hinh - Mycoplasma (36.67%) vd vi khudn (25,83%). Vi khudn gap chii yiu la Phi cdu (18.33%). H.lnfluenza (7,50%) Trong nghien cuu ndy chung tdi gap duy nhdt I benh nhi nhiem Cum A (0.83%). Con l(fi la khong tim duac nguyen nhdn (36,67%).
3.2.4. Khdng sinh dd cua vi khudn gdy binh Hinh 5: Khang sinh do ciia Ph^ c4u gay viem phoi thiiy
12.50%
' 14.17%
S05S 100%
Trong VPT, phe cdu nhay cam cao vdi Vancomycin (100%). Ciprofloxacin (91.67%), Ceftriaxon (64,17%). Phe cdu khdng Azithromycin vdi ty le cao (97,50%). Meronem (87.5%), Augmentin (85,83%)
Hinh 6; Khang sinh do cua H.lnfluenza gay benh viem phoi thiiy
OijNhsv
Augmentin
Piperacilin
Azithromycin
Meronem
177.8%
194.17%
""—l:
•94.17%HOI NGH! TOAN Q U 6 C Vg CAC B £ N H NHigM T R O N G V A HIWAIDS 6 T R £ EM N A M 2013
Trong VPT, H.lnfluenza c6n nh^y cAm cao vai nh6m Ciprofloxacin (97,50%), sau do la Imipenem (95,80%), Meropenem (94,17%), Azithromycin (94,17%).
Piperacilin (77,80%), Augmentin (70.56%).
Trong VPT do Mycoplasma. 77,27%
dugc diSu trj vai kh^ng sinh nh6m Marcrolide. 15,90% b?nh nhi dugc di^u tri vai nhom Quinolon cho hi?u qu^ tot.
IV. BAN LUJC^N
4.1. M$t so dSc diem djch t^ ciia bfnh nhSn VPT:
Ve dp tu6i mSc benh, b?nh nhi VPT co dp tuoi mSc b?nh cao ban so vai benh nhi viem phoi. Theo nghien cuu ciia Dao Minh Tudn va cong su nSm 2011, 83,20% s6 tre bj viem phoi duai 12 thang tuoi. con lai 16,8%
tre tren 1 tuoi [ 1 ]. Trong VPT, tuoi mdc benh trung binh la 4.7. Tre VPT do Mycoplasma CO tuoi trung binh cao han so vai cac nguyen nhan khac.
Ve giai, ty le benh nhi nam nhieu ban so vol benh nhan nu, dieu nay cung phii hgp voi mo hinh b?nh tat a tre em Viet Nam noi chung.
Benh nhi a thanh thi cao han nong thon.
dieu nay co \hk la do di^u kien dja ly, kinh xk.
NhiJng benh nhi a thanh thi co dieu ki?n kinh te cao han, tam ly muon kham va dieu tri a tuyen tren.
73,30% benh nhi da dugc diiu tri truac khi nhap vien nhung khong khoi.
Trong so cac benh nhi dS di^u tri truac khi vao vien, da s6 diau tn tai nha 69,30%, diiu tn tai ca so y xk 30,70%. Di6u nay co tha la do nguyen nhan gay b?nh thay doi, tinh khang khang sinh va cung co tha do mot s6 dac diem lam sang kho phan biet. phat hien 58
ra VPT ddn din bo sot benh, nham voi cac benh viem duang h6 hap tran.
4.2. Dac di^m lam sSng VpT:
Tri?u chung n6i bat nhit trong VPT la ho (100%) va s6t (94.20%). Trieu chirng khac it gSp han nhu kho tha (8.3%), dau ng^rc (3.3%). Kit qua nay phii hgp vai nghiem ciru VPT cOa ZOU Li-Ping tran 76 truang hgp b?nh nhi tai Trung Quoc [2].
Ran a phoi nghe dugc a 43.30%. Nhu vay. 56.70%) cac truang hgp khong nghe thay ran rat de bo sot benh neu nhu benh nhi khong dugc chup X-quang, d^c biet la nhOng b?nh nhi dieu tri tai nha.
25% truang hgp phat hien dugc giam thong khi phoi va cbu yeu a tre Ion.
4.3. D^c diem can lam sang VPT Hinh anh X-quang dian hinh gSp 6 '/4 truong hgp. Diau nay co tha do tre nho co kha n3ng khu tru ton thuang kem hem a nguai lorn
Tran dich mang phoi tren benh nhi VPT nghi nhieu dan nguyan nhan do Mycoplasma han la cac nguyan nhan khac. Kat qua nay tuang X\f vai nghien cim cua You-Sook Youn nam 2010 [31.
VPT do Mycoplasma, bgch cau thucmg binh thudng, CRP tang.
4.4. Nguyen nhan gay benh Theo y van. VPT thuong gap nhat la do phe cau. Nhimg hien nay. chiing toi thay Mycoplasma gap nhieu hon. Ket qua phii hop voi nghien cuu ciia ZOU Li-Ping [2]. Dieu nay co tha do sy quan tam hon den nhom vi khuan khong dian hinh.
4.5. Khang sinh Ah cua vi khu^n gay benh
Nhin chung, cac vi khuan con nhay rat cao vai nhom Quinolon. Tuy nhien, nhom
Y HQC VIET NAM THANG 10 - SO 2/2013
Quinolon chua dugc khuyin cao sir dung rpng rai cho tre em vi tac dung phy ciia nhom nay. Ngoai ra, phi cku nh^y cam 100% v6i Vancomycin, H.lnfluenza nhay cam cao voi nhom Azithromycin va Carbapenem.
Chung toi khong chay dugc khdng sinh do cho Mycoplasma. Tuy nhien, tran thuc te lam sang cho thay da co hiSn tugng Mycoplasma khang voi nhom Macrolide.
15,9% benh nhi VPT do Mycoplasma chuyan sang nh6m Quinolon dieu tn cho hi?u qua ro ret, benh nhi het sot va X-quang phoi tro vl binh thudng.
V. KET LU^N
1. VPT thudng gSp d tre Idn, nam gap nhieu han mt
2. Triau chung lam sang thudng gap la ho,sot
3. Nhieu trudng hgp khong nghe thay ran d phoi can dugc chup X-quang
4. VPT thirdng do Mycoplasma^ phe cau va H.lnfluenza.
5. Trong VPT, cac vi khuan con nhay cao vdi nhom Quinolon. Pha cau nhay cam 100%
vdi Vancomycin, H.lnfluenza nhay cam cao vdi nhom Azithromycin va Carbapenem.
TAI U^U T H A M KHAO
1. Dao Minh Tu^n va cs (2012). Nghien CLTLI cSn nguyen va mire dp d l khang khdng sinh ciia vi khuan gay viem phoi tre em tir I thang den 5 tii6i. T^p chi Y hpc Vi?t Nam, tap 397, t r . 2 l 6 - 2 l .
2. Z O U Li-Ping, Y U A N Rui (2010). Clinical analysis o f childhood lobar pneumonia in 76 cases. Chinese .lournal o f Contemporary Pediatrics, Vol.13, Issiie(l2): 995-996.
3. You-Sook Youn et al (2010). Difference o f clinical features in childhood Mycoplasma pneumoniae pneumonia. B M C Pediatr. 2010;
10: 48. Published online 2010 July 6.
4. W H O (2006). The management o f acute respiratory infection in children, pp.l-77.
