Y HQC VigT NAM THANG 10 - s 6 1/2013
NGHIEN CU'U DAC DIEM VI KHUAN 6" BENH NHAN VIEM PHOI T H 6 ' MAY Pham Thai Dung*, Do Quyk*
T 6 M TAT
Tir thang 01/2009 den thang 12/2011, chiing toi tien hanh nghien cdu dSc diem vi khuan hoc d 63 benh nhan (BN) viem phoi thd mciy (VPTM), dieu tri tai khoa hoi sifc tich ci/c (HSTC) B?nh vl?n 103. Ket qua cho thay: Vi khuan gay viem phdi thd may chii yeu la trUc khuSin Gram am (79,31%) g^p nhieu nhat !a P.aeruginosa (36,21%). Vi khuan Gram du'dng (20,69% ) trong do S. aureus chiem ti le cao (8,62%).
P.aeruginosa khang vdi hau het cac loai khang sinh, chi con nh?y vdi imipenem, ticarcillme/davulanic. Ecoli khang cao vdi ampicilline, amoxicilline, cefotaxime (84,61%). D§ c6 Ecoli khang v6i imipenem va ertapenem (7,69%). S.aureus khang 100% vdi gentamycie, kanamycine, amikacine, oxaciline va nofloxadne, chu'a khang vdi vancomycin. Viem phoi thd may khdi phat muon chii yeu gSp vi khuan Gram am chiem phan Idn: 72,42%, hay g3p: P.aeruginosa, K.pneumoniae, Ecoli, S.aureus...
Tu'khda:'^\ khuan, Viem phoi thd may.
SUMMARY
BACTERIAL CHARACTERISTICS OF VENTILATOR ASSOCIATED P N E U M O N I A
We studied bacteriological characteristics in 63 patents with ventilator associated pneumonia (VAP), treating at the intensive care unit (ICU) of Hospital 103, from 01/2009 to 12/2011. The results showed that: The bacteria are mainly Gram-negative bacilli;
79.31%, Gram-positive bacteria; 20.69%. P.aeruginosa is resistant to most antibiotics, only sensitive to imipenem, ticarcilline /clavulanate. E. coli resistant to Ampicilline, amoxiciliine, cefotaxime (84.61%). There is E.coli resistant to imipenem and ertapenem (7.69%). S.aureus is totally resistant to gentamycie, Kanamycine, amikacine, oxaciline and nofloxacine, but S.aureus still is sensitive to vancomycin. Pneumonia- onset ventilator met mainly Gram-negative bactena accounting for the majority: 72.42%, common:
P.aeruginosa, K.pneumoniae, E. wli, S, aureus...
Keywords: ZacXe.t\a, ventilator associated Pneumonia.
I. DAT VAN D 1
Ty le mac viem phdi thd may (VPTM) khoang 8-20% d tat ca cac benh nhan (BN) tai khoa hoi sire va 2 7 % d benh nhan t h d may. Ti le tir vong
* Benh vien 103 ~ Hpc vien Quan Y Phan bien khoa hpc: PGS. TS Nguyen Thai SOn 100
do viem phoi t h d may thay ddi tir 24 tdi 50% va cd the len tdi 7 6 % [ 5 ] .
C3n nguyen vi khuan gay viem phdi thd may ludn khac nhau d cac benh vien, cac quoc gia.
Thdi gian gan day da cd nhieu bao cao ve su"
xuat hien cac chiing vi khuan da khang thudc nhu": Staphylococcus aureus khang methiciilin, vi khuan Gram am tiet Beta lactamase pho rdng, Pseudomonas aeruginosa, Aclnetobatier baumannii khang da thuoc gay khd khan trong dieu tri va t i le tir vong cao.
Muc tieu nghien ciru ciia chung tdi nhSm: Xac dinh dac di&n vi khuan d benh nhan vi&n phoi thd may tai khoa hoi sdc tich ci/c Benh vien 103.
II. OOI TU'DNG VA PHLrCTNG PHAP NGHIEN CUTJ 2 . 1 . Do! ti/tfng nghien c u ^
Tir thang 01/2009 den thang 12/2011, chiing tdi tien hanh nghien culi bao gom 63 BN, 11 nff va 52 nam, tudi trung binh 54,27 ± 18,1 tir 21-81 tuoi, du'dc chan doan viem phdi t h d may, d cac benh If nen nhu' sau: Benh noi khoa 18 BN, chan thu'dng: 35; Hau phau: lOBN."
- Tieu chuan chan chon benh nhan:
-H Tat ca cac BN du'dc t h d may xam nhap tai khoa HSTC Benh vien 103.
+ Tieu chuan chan doan xac dinh VPTI^ theo ATS nam 2005 [ 5 ] :
1. Dat ong ndi khf quan (NKQ) thd may tren 48 gid.
2. X quang phdi cd hinh anh tham nhiem mdi, tien trien hoac keo dai
3. Nhiet dp >38,5°C hoac <35°C.
4. Dich phe qu
5. an cd mil hoac mau vang dac.
6. Bach cau mau ngoai vi >10 G/L hoac <4 G/L.
7. Cay dich khf, phe quan cd vi khuan gay benh, cay mau (•••).
8. Diem nhiem khuan phoi lam sang (CPIS) > 6.
Chan doan xac djnh khi cd 2 tieu chuan (1), (2) va it nhat cd 2 trong cac tieu chuan (3), (4), ( 5 ) , ( 6 ) v a ( 7 ) .
Tat ca 63 BN deu cd 2 tieu chuan (1) va (2), trong dd cd 51 BN cay khuan tai thdi diem Ti du'dng ti'nh, 52 BN cd CPIS > 6 diem, 26 BN co nhiet dp > 38,5°C hoac < ZS^c, 40 BN cd tang tiet ddm mil hoac vang dac, 53 BN cd bach cau
>10 G/L hoac < 4 G/L.
YHOC VIET NAM THANG 10 - S6 1/2013
-Tieu chuan loai trir: Cd tinh trang nhiem khuan tnrdc nhap khoa hoac tru'dc 48 gid thd may trong dieu tri theo ddi khdng cd nhiem khuan tiet nieu, nhiem khuan huyet hay catheter tinh mach du'di don....; Benh nhan chuyen tir ndi khac den da dat dng NKQ, MKQ va thd may; Benh nhan tir chdi tham gia nghien ciru.
2.2. Phu'dng phap nghien cuTu - Nghien culi tien ciilj, md ta, theo ddi doc theo thdi gian.
- Xac dinh ti le cac loai vi khuan va mu'c dp khang khang sinh ciia mdt sd loai vi khuan hay gap. Lay dich phe quan ngay sau khi dat NKQ hoac khi chuyen BN tir phdng md ve khoa HSTC theo phu'dng phap rira phe quan phe nang tdi thieu (mini-BAL) bang dng thdng 2 ndng cd nut bao ve dau xa (Aspisafe 2 ciia hang Vygon). Xet nghiem nudi cay va dinh lu'dng vi khuan trong dich phe quan du'dc thu'c hien tai khoa Vi sinh Benh vien 103. Ngu'dng xac dinh siT nhiem khuan la sd VI khuan > 10" vi khuan/ml khi cay djnh lu'dng djch phe quan.
III. K I T Q U A NGHIEN CU'U
3 . 1 . D3c diem vi khuan d benh nhan viem phoi t h d may Bangl.Tx le cac loai vi khuan
Loai vl khuan Mpt loai vi khuSn
Gram (-) Gram {+) fia vi i<iiuan
P, aeruginosa va E,coli A,baumannii va K,pneumonlae P,aeruqinosa va S,epidermldls
£,coii va S.pneumoniae P,aeruqinosa va S,pneumoniae
Benh nhan cay dich phe quan dWdnq tinh n=Sl
44 36 8 7 2 1 2 1 1
Tile (100%) 8 6 , 2 7
70,59 15,68 1 3 , 7 3 3,92 1,96 3,92 1,95 1,96 Kit qua cua nghien cdu cho thay: Trong tdng so
63 BN lay djch phi quan bang phu'dng phap mini-BAL, CO 51 BN mau djch phi quan du'dng tinh khi nudi cay vi khuan chiim 80,95% (51/63).
Trong sd 51 BN co kit qua cay dich phi quan dudng tinh co 45 BN du'dng tfnh vdi mpt loai vi khuan, va 7 loai du'dng tfnh vdi vdi hai loai vi khuan thu dude 58 mau vi khuan. Kit qua nay cao hdn so vdi cac tac gia nddc ngoai nhd:
Flanagan P.G. nam 2000 cung thi/c hien nghien
cdu bang phu'dng phap mini-BAL thay dp nhay 74% va dp dac hieu 70%. Fabregas N. nam 1999, ichi so sanh vdi tieu chuan chan doan VPTM la giai phau benh cho thay phu'dng phap mini-BAL co dp nhay la 39%, do dac hieu la 100%. Papazian L.
nam 1995, cung thi/c hien so sanh vdi tieu chuan chan doan VPTM bang xet nghiem giai phau benh cho thay phu'dng phap mini-BAL co do nhay la 67% va dp dac hieu 80% [6].
~~—• Sdvl khuan
Loal vl khuan ____
Gram a m P, aeruqinosa
£ coll K. pneumoniae A. baumannii Burkholderia cepacia Gram du'dng
S.aureus S,epidermidls S.pneumoniae
So vl khuan dWdnq tinh n^SS
46 21 13 7 3 2 12 5 3 4
Tyle (100%) 79,31 36,21 22,41 12,07 5,17 3,45 20,69 8,62 5,17 6,89
Y HQC VtgT NAM T H A N G 10 • S6 1/2013
Ket qua cho thay: Cac__vi khuan Gram am
chiem ti I? 79,31% trong tdng so vi khuan thu du'dc, cac vi khuan Gram du'dng chiem 20,69. Ket qua nay cung phii hdp vdi cac tac gia trong va ngoai nu'dc, nhan xet: Hau het cac bao cao deu ghi nhan ti le vi khuan Gram am chiem da sd, cd the tren 80% [6], [7].
Khi phan tich cac loai vi khuan, chiing tdi hay g5p nhat la P.aeruginosa 36,21% tiep theo la
Bang 3: Mdi lien quan giu'a khdi phat sdm va muon ciia viem phdi va vi khuan
Eco//chiem 22,41%. Da sd cac tac^gia deu ghi nhan P.aeruginosa chiem tl le cao nhat, sau do la
£co//ho§c S.aureus. Ngoai ra, trong nghien cii'u ciia chiing toi gap 11,11% (7/63) cac tru'dng hdp VPTM do nhieu tac nhan, thap hdn Giang Thuc Anh tai Bach Mai (21,2%) [1] va Mai Xuan Hien tai Benh vien 103 (51,7%) [2]
^"•^•^^ Kieu khdi phat
^~---~~-.Ji/PTIvi Loal vi khuar}"^---^,^^^^^
VI khuan Gram Sm P.aeruginosa
£ coll K, pneumoniae A, baumannii Burkholderia cepacia VI khuan Gram difdng S,aureus
S,epidermidis S,pneumonlae Tong so vt khuan
Khdi phat sdm Sdvl khuan (n)
4 3 1
6 3 3 10
Tile % 6,90 5,17 1,72
10,34 5,17 5,17 17,24
Khdi phat mudn So vl khuan (n)
42 18 12 7 3 2 6 5 1 48
Tile % 72,42 31,03 20,69 12,07 5,17 3,45 10,34
8,62 1,72 82,76
Ket qua cho thfy d nhdm khdi phat mudn vl khuan Gram am chiem phan Idn: 72,-12%, hay gap:
P,aeruglnosa, A pneumoniae, E,coli, 5,aureus„, 3.2. Ket qua ngiiien cu'u v'e i<hang sinll do
Bleu do 1: Ti le khang khang sinh ciia P.aeruginosa c( nhom 1
Ket qua cho thay: M&c do khang khang sinh aia P,aeruglnosa cao nhW: Khang vdi gentamydn (85,71 %), pefloxacin (95,24%) Khang dao dqng gan 60% vdi cac khang sinh: ceftazidime, cefepime, clprofioxadne, ofioxacine, levofloxaclne, Nghien cWu ciia chung toi cung thu dWdc P,aeruginosa cm nhay vdi Imipenem (95,24%), ticarcilline/clavulanic (57,14%) va vdi amikacine (52 38%)
102 ^'
Y HQC VigT NAM THANG 10 - S 6 1 / 2 0 1 3
giSudd2:T\ le khang khang sinh cua E.coli d nhom 1
Kit qua cho thay: E,coll la vi khuan nhieu th& 2 thu dWdc trong nghien cWu, E,coll cd ti le khang cao vdi cac khang sinh nhW: cefotaxime (84,61%), ceftriaxone (61,54%) nhutig con nhay vdi amikacine (84,61%), cefoperazone (84,61%) va ciprofloxacin 46,15%, Da cd E,coll khong nhay vdi imipenem va eitapenem.
Bang4iKet qua khang sinh do ciia S.aureus d nhom 1 (n=5)
" —-.^__t4u'c do khang Loal khang sinh ~- _ Amo+Clavuianic (AMC)
Cefuroxime{CXivi) Ceftriaxone (CTX) Vancomycine (VA) Fosfomycine (FOS) Imipeneme (II^P) Ertapenem (ETP) Kanamycine (KA) Gentamycine (GM) Amikacine (AN) Nofloxacine (NOR) Ciprofloxacine (CIP) Ofioxacine (OFX)
So lu'dng BN (n=S) Khang
4 4 4
5 5 5 5 3 4
Trung gian
2
1 Nhay
1 1 1 5 3 5 5
1 1
Trong nghien cult cua chung toi S.aureus khang 100% vdi cac khang sinh nhd gentamycine, kanam^ne, amikacine, oxaciillne va nofloxacine. Khong gap chung nao khang vdi imipenem, ertapenem va vancomycin. Nguyen Tuan Minh cho thay S.aureuschi con nhay cam vdi vanaimycin 100%, clindamycin 25%, ceftazidime va co-tn'moxazole cung ty le 12,5% [3].
Bam a 5: Ket qua khanq sinh do cua K. pneumoniae d nhor - ^ Mii'c dp khang
Loal khang sinh _ _ Amo + Clavulanic (AMC)
Ceftriaxone (CRO) Cefotaxime (CTX) Ctefoperazone (CFP) Cefepime (FEP) Amikacine (AN) Ciprofloxacine (CIP) Imipeneme (IMP) Ertapenem (ETP) Meropenem (I^EM)
n 1 (n=7) So lu'dng benh nhan (n=7) Khang
4 1 6
Trung gian 1 1
Nhay
6
7
2
6
7
1
7
7
7
7
Y Hpc VigT NAM THANG 10 - SO 1/2013
Mu'c dp khang khang sinh ciia Klebsiella khdng cao. Oa so khang sinh lam khang sinh dd deu cho ket qua nhay cao vdi K.pneumoniae.
Theo nghien ciru cua Nguyen H^u Hong va Nguyen Thj Vinh nSm 2001, d Viet Nam chi cdn rat it chiing vi khuan nhay cam vdi cefotaxim va ceftazidime. Theo Pham Hiing Van nSm 2009, nghien culJ thu'c trang de khang khang sinh d 16 benh vien ciia Viet Nam cho thay P.aeruginosa khang vdi amplcillin la 9 8 % , ciprofloxacin 53%, levofloxacin 44%, gentamicin 7 2 % va imipenem la 1 % [4].
Theo khuyen cao ciia ATS thi de dieu trj vi khuan gay VPTM nen dung cac thudc khang sinh tazocin hoac imipenem ket hdp vdi nhdm aminoglycoside hcSc quinolon vi vi khuan gay VPTM chii yeu la vi khuan da khang [ 5 ] .
Nghien ciTu ciia chung toi cd sd lu'dng vi khuan chu^ Idn, tuy nhien ket qua khang khang sinh tu'dng ddi phu hdp vdi cac benh vien khac.
IV. K ^ L U A N
Vi khuan gay viem phoi thd may chu yeu la tri/c khuan Gram am (79,31%) trong do gap nhieu nhat la P.aeruginosa (36,21%). Vi khuan Gram du'dng (20,59%) trong dd S. aureusc\\\eru ti le cao (8,62%). P.aeruginosa khang vdi hau het cac loai khang sinh, chi cdn nhay cao vdi imipenem, ticarcitline/clavulanic. E.coli khang cao vdi ampicilline, amoxicilline, cefotaxime (84,61%).
Da cd E.coli khang vdi imipenem va ertapenem (7,69%). S.aureus khang 100% vdi gentamycie, kanamycine, amikacine, oxaciline va nofloxacine, chuci khang vdi vancomycin. Viem phoi thd may khdi phat muon chii yeu gap vi khuan Gram am chiem phan Idn: 72,42%, hay gap: P.aeruginosa, K.pneumoniae, E.coli, S.aureus...
TAI L l | U T H A M KHAO
1. Giang Thuc Anh (2004), Dinh gia s&dung khang sinh dieu tri nhiem khuan benh vien tai khoa dm tn tich eye Benh vien Bach Mai 2003-2004, Luan v3n thac %\ y hoc, Dai hoc Y Ha Noi.
2. Mai Xuan Hien (1996), Nghien cuU vi khuan va lieu phap khang sinh tai cho de dir phong va dieu tri nhiem khuan phdi phe quan benh vien d benh nhan thong khi nhan tao, Luan an pho ten sy khoa hoc y dUOc, Hoc vien Quan y.
3. Nguyen Tuan Minh (2008), Nghien ciTu vi khuan sinh beta-lactamase hoat phd rdng gay nhilm khuan hd hap d benh nhan thd may, Luan vfin thac si y hoc. Hoc vien Quan y.
4. Pham Hung Van, Pham T h i i Binh, Le Thj Kim Anh (2009), "Nghien ciru da tnjng tam khao s^t tinh hinh de khang cac khang sinh ciia tru'e khuan Gram (-) de moc gay nhiem khuan benh vi^n phan lap tir 1/2007 den 5/2008", Y hoc Thanh pho Ho Chi Minh, 13(2), tr.138-148.
5. American-Thoracic-Society (2005), "Guidelines for tfie management of adults with hospital acquired, ventilator associated, and healthcare- associated pneumonia", Am J Respir Crrt Care Med, 171(4), pp. 388-416.
6. Papazian L., Thomas v., Garbe L., et al.
(1995), "Bronchoscopic or blind sampling techniques for the diagnosis of ventilator- associated pneumonia". Am J Respir Crlt Care Med, 152, pp. 1982-1991.
7. Werarak P., Kiratisin P., Thamlikitkul V.
(2010), "Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia in Adults at Sinraj Hospital: Etiology, Clinical Outcomes, and Impact of Antimicrobial Resistance", J Med Assoc Thai, 93 (1), pp. 126-138.
