Y HOC VIET NAM THANG 6 - SO 1/2015
Ti LE NHIEM KHUAN BENH VIEN, VI KHUAN GAY BENH VA TI LE DE KHANG CARBAPENEM
TAI KHOA HOI SITC TICH CUC BENH VIEN CHO" RAY
T O M TAT
Myc tieu nghien cdu: Xac dinh ty le nhiem khuan benh vien, vi khuan gay benh va ttnh hinh de khang Carbapenem tai khoa Hoi sdc cap cdu benh vien Chd Ray. Tien hanh nghien ciru tien cdu, cat ngang tren 284 benh nhan tir 01/12/2013 den 30/09/2014 tai Khoa Hoi sij'c tieh cUc Benh vien ChO Ray. Ket qua cho thay, tuoi trung binh ciia nhdm nghien cu'u la 59 tuoi, chii yeu tap trung d Ida tuoi > 50, nam nij" co ti le tu'dng du'dng nhau. Ti le nhiem khuan benh vien la 5 1 % , trong so 36 88,2% xay ra tai Benh vien Chp Ray, so con lai td cac benh vien khac chuyen den.Viem phoi nhiem khuan benh vien chiem 45,4%, nhiem khuan 6 bung chiem 22,3%, nhiem khuan da, mo mem chiem 6,4%, nhiem khuan bet nieu chiem 4,6% va nhiem khuan huyet chiem 3,2%.Ti le nhiem khuan benh vien khi nhap Khoa Hoi siTc tich ci/c Benh vien Chd Ray la 38,3% va thdi gian trung binh xuat hien nhiem khuan benh vien la 8 ngay. Tac nhan gay benh thu'dng gap la: Acinetobacter haumannii S3,9%, Klebsiella spp 12%, Staphylococcus aureus 8,8%, Pseudomonas aeruginosa 7,7%, Enterococci 6 , 1 % , E.coli 3,3%. Ti le khang carbapenem ciia Acinetobacter baumannii la 95,9%, Pseudomonas aeruginosa la 71,4%.
TW khoa: Nhieni khuan benh vien. Hoi sde tich ci/c, Benh vien Chp Ray
S U M M A R Y
SURVEY OF HOSPITAL-ACQUIRED INFECTION RATE, BACTERIA, AND CARBAPENEM RESISTANCE RATE
A T T H E I N T E N S I V E CARE U N I T , CHO RAY HOSPITAL Aim of study /sto determine prevalence of hospital acquired infection rate,bacteria and Carbapnem resistance rate at the Intensive care unit, Cho Ray hospital. A prospective cross sectional study was done from 01/12/2013 to 30/9/2014 in 284 patients. The result showed that mean age was 59 years old, male
* BV Chd Ray; Bp mon Hoi s&c - Cap c&u - Chdng dpc, Dai'hpc YDddc TP.HCM
Chiu trach nhiem chinh: Pham Thi Ngpc Thao Email: [email protected] Dt: 0903628016 Ngay nhan bai: 4/4/15
Ngay phan bien khoa hpe: 4/5/15 Ngay duyet bai: 20/5/15
P h a m T h i Ngoc T h a o * to female was the same. The hospital acquired infectionwas 5 1 % in which pneumonia was 45,4%, intra-abdominal infection was 22,4%, cellulitis and soft tissue were 6,4%, unnary tract infection was 4,6%, sepsis was 3,2%, SIRS was 2,8%, unknown was 12,4%. Mean time from Intensive care unit admission to have hospital acquired infection was 8 days.
Organisms cause hospital acquired infection were Acinetobacter baumannii 53,9%, Klebsiella spp 12,1%, Staphylococcus aureus 8,8%, Pseudomonas aeruginosa 7f7%, Enterococci spp 6 , 1 % and Escheria coll 3,3%. The Acinetobacter baumannii resisted Carbapenem was 95,9%, Pseudomonas aeruginosa resisted Carbapenem was 71,1%.
Keywords: Hospital-acquired infections, intensive care, Cho Ray hospital
I. DAT VAN OE
Nhiem trung benh vien, dac biet la do cae vi khuan da khang dang la mot van de sdc khde dang bao dpng tai nhieu qudc gia vdi ti le de khang kharig sinh ngay cang tang cao. De khang khang sinh lam tang ti le t d vong, keo dai thdi gian dieu tn va tang chi phi dieu trj. 6 Chau Au cd khoang 18000 ca t d vong moi nam do vi khuan Gram am da khang thuoc [2]. Chi phi dieu tri cho mot benh nhan nhiem vi khuan khang thudc thddng tang len mddi lan hoac cao hdn so vdi chi phi dieu trj cho benh nhan nhiem vi khuan nhay cam do thdi gian nam vien lau hdn va phai sd dyng thuoc dat tien hdn [3]. Xac dinh ti le nhiem khuan benh vien, deu diem nhiem khuan, tae nhan gay benh va tinh hinh de khang cua vi khuan vdi Carbapenem giup sd dung khang sinh an toan, hieu qua va giam tinh trang de khang khang sinh von dang xay ra rat pho bien hien nay.
Muc tieu nghien cdu: Xic dinh ty le nhiem khui'n benh vien, tic nhin giy benh vi tinh hinh de khing vdi khing sinh Carbapenem tai khoa Hoi sWc tich cWc, Benh vien Chd Ray
Y HOC VIET NAM THANG 6 - SO 1/2015
II. DOI TUpTJC VA PHLrCTvJG PHAP NGHIEN CUTJ Thiet ke nghien cu'u: Tien cdu, cat ngang md ta.
Doi tu'dng nghien cu'u:
Tieu chui'n chgn benh: Tat ca cac benh
nhan vao khoa Hoi siTc tich cdc tru'dc 8 gid sang ngay khao sat va con nam dieu tn tai khoa d thdi diem khao sat. Td thang 01/12/2013 den thang
30/09/2014, moi thang 1 ngay vao tuan thir 3 cita thang.
Tieu chui'n loai trW:
- Benh nhan se du'dc chuyen trong ngay.
- Benh nhan du'dc tien lu'dng tdvong trong ngay.
Cac du" lieu thu thap di/a vao benh sd, kham lam sang, can lam sang theo bang cau hoi nghien cirtJ soan sin va tren benh an mau. So lieu du'dc trinh bay du'di dang ti le, trung binh va
x.d ly bang phan mem Stata 10.0III. KET QUA NGHIEN CCrU
Td thang 01/12/2013 den thang 30/09/2014 da thu'c hien du'dc 11 lan khao sat vdi 284 benh nhan.
Ti le nhiem khuan benh vien la 51%. Co 256 benh nhan du'dc sd dung khang sinh ehiem ti le 90,1%.
Bing 1: Dac diem benh nhan
Tuoi Trunq binh
59
12-<18tu6i 1,8%
18-64 tuoi 51%
>65 tuoi 47,2%
Gidi Nam 150 (52,8%)
NiJ 134 (47,2%)
Sddo 1: Nguon benh nhan vao hoi sdc tfch ci/c:KhaCpng dong BV khac
35% Khoa khac trong
BV 29%
Phan ldn nguyen nhan benh nhan nhap khoa Hoi su'e tich cdc la do nhiem khuan va co den 42,9% cd benh ly nen kem theo nhu" Oai thao dddng (10,8%), suy than (8,4%), benh ly ac tinh (7,2%), dot quy nao (6,3%). Ngoai ra, benh nhan du'dc thu'c hien eac thu thuat nhu' dat sonde tieii (87,7%), 6at noi khi quan (87%), dat catheter tmh maeh trung tam (77,1%), chay
than nhan tao (20,1%) va eac thii thuat it xam lan khac.
- Vi tri nhiem triing benh vien: viem phoi nhiem khuan benh vien chiem da so trong nhdm nghien cdu nay, sau do la nhiem khuan 6 bung, nhiem khuan da va mo mem.
- Thdi gian td khi vao khoa Hoi siTc tich cu'c den khi khdi phat nhiem khuan benh vien trung binh la 8 ngay va 6d(ic phan bo nhu' sau
Sddd2:lhii'\ gian nhiem khuan benh vien50.00%
40.00% ^ 30.00% \
W^. '»*»**»-»-«^
Y HOC VIET NAM THANG 6 • S 0 1 /2015 Tac nhan gay nhiem triing benh vien: tac
nhan nhiem khuan benh vien pho bien nhat la Acinetobacter baumanii, Klebsiella spp va Staphylococcus aureus
Tinh hinh d"e khang vdi Carbapennem: chi cd 4 , 1 % Acinetobacter baumannii con nhay vdi Carbapenem va 2 8 , 1 % Pseudomonas aeruginosa con nhay vdi Carbapenem.
IV. BAN LUAN
Nhiem khuan benh vien dac biet la do cac vi khuan da khang dang la mpt van de sdc khoe dang bao dpng tai nhieu qudc gia vdi t i le de khang khang sinh ngay cang tang eao, lam tang ti le t d vong, keo dai thdi gian dieu t n va tang chi phi dieu tri. Khao sat nhiem khuan benh vien va sd dung khang sinh tai khoa Hoi sdc tich cdc giup cai thien tinh hinh sir dyng khang sinh d cac benh vien Idn tai Viet Nam.
Trong nghien ciTu eua chung toi, tuoi trung binh la 59 tuoi, trong do 47,2% > 65 tuoi (38%
tir 64-84 tuoi, 9,2% >85tu6i). Nam 52,8%, n d 47,2%. Tac gia Vu Dinh Phil tong ket nghien ciru VNRES tai Viet Nam tuoi trung binh la 6 1 , nam 64%, n d 36% [ 6 ] . Nghien cdu ciia ECDC dp tuoi trung binh cao hdn la 64 tuoi (52 tuoi d Latvia va 71 tuoi d Anh -Wales), phan bo dp tuoi tddng t d nghien ciru cua chung tdi 48,9% > 65 tuoi (trong do 3 8 , 1 % 65-84 va 10,8% > 85 tuoi). Tuy nhien t l ie nam thap hdn nu", nam/nd 0,89/1 [4]
Nguon benh nhan vao Khoa Hoi sire tich cdc trong nghien ciru ciia chung toi la 5 7 % tir cac khoa lam sang khac ciia benh vien, 3 5 % dddc chuyen tu' cac benh vien khac, nhiem khuan cpng dong 7%. Ly do nhap Hoi sire tich cde do nhiem khuan chiem 5 7 % , sau phau thuat cap ciru 2 1 % , benh khong nhiem khuan chiem 1 1 % , da chan thu'dng 9%, sau phau thuat chddng trinh 2%. Nghien cii'u Vu Oinh Phu cho thay nguon benh nhan vao Hoi sdc tich cdc tir cpng dong 4 4 % , cung benh vien 3 1 % , benh vien khac 20%, va nguyen nhan nhiem khuan chiem 4 6 % , benh khong nhiem khuan 4 0 % , da chan thddng 7%, sau phau thuat cap cdu 6%, sau phau thuat chddng trinh 1 % [ 5 ] , Cd sd khac biet dang ke glu'a nghien ciru ciia chimg tdi va eiia Vu Dinh Phu cd le la do thu thap cac sd iieu t d nhieu ddn vj Hoi sire tich cde noi, ngoai ciia cac benh vien vdi cac dac diem khac nhau. Cac khoa Hdi sdc tl'ch cdc npi ciia cac benh vien hau het deu nhan benh nhan nang t d cap cdu, benh nhan dot qui.
nhoi mau cd tim nhieu thi ti le benh nhan nhaj) vien t d cpng dong se tang len va t i le vao Hoi sdc tieh cu'c do nhiem khuan se giam xuong. T | i Benh vien" Chd Ray, khoa Hoi sdc tich c i / c j a hoi sde npi ngoai chung, cac khoa lam sang hau het deu cd ddn vi hoi sdc rieng ciia minh, do do benh nhan vao cap eiru thu'dng du'dc chuyen len cae khoa lam sang dieu t n va khi xuong Hoi ^^'t tich cu'c thu'dng la benh rat nang va hau het da CO n h i i m khuan benh vien. Benh nhan co benh ly nen kem theo chiem ti le 42,96%, nghien edu VNRES eiia Vu Dinh Phil la 4 6 , 8 % [ 6 ] .
Chiing toi ghi nhan tai khoa Hdi sdc tich cdc Benh vien Chd Ray co 8 7 % dat noi khi quan, 87,7% CO sonde nieu dao, 7 7 , 1 % cd catheter tinh mach trung tam va 2 0 , 1 % cd chay than nhan tao. Nghien cdu ciia VNRES cua Vu Dinh Phil cho thay 50,5% dat noi khi quan, 4 9 , 1 % cd sonde nieu dao, 2 7 , 6 % cd catheter tinh mach trung tam va 7,6% co chay than nhan tao, tat ca deu thap hdn han so vdi ciia chiing toi. Dieu nay giai thi'ch du'dc ti le benh nhan diing khang sinh la 9 0 , 1 % cao hdn nghien cdu VNRES thdc hien tai cac benh vien khac tai Viet Nam chi co 60%
benh nhan diing khang sinh [ 3 ] .
Ti le nhiem khuan benh vien tai khoa Hoi sdc tl'ch cdc Benh vien Chd Ray la 5 1 % , so vdi nghien ciru VNRES cua Vu Oinh Phu tai cac khoa Hoi sdc tl'ch cdc ciia cac benh vien tuyen trung ddng khac thi t i le nay dao dpng tir 3,9% - 63,8% va trong mpt nghien cdu dddc thdc hien tai My 2012 la 3 8 , 5 % [ 1 ] . Nguon goc cua nhiem khuan benh vien da sd t d benh vien hien tai, nghien cdu ciia chiing toi la 88,2%, VNRES la 8 4 % [ 3 ] , ECDC la 5 4 . 7 % nhiem khuan tai cung benh vien, 3 1 . 1 % tai benh vien khac va 14.2%
khdng ro [ 4 ] .
Ket qua nghien cdu cho thay, t i le nhiem khuan benh vien tai khoa Hoi sdc ti'ch cdc, Benh vien Chd Ray thu'dng gap nhat la viem phoi 45,4%, ke den la nhiem khuan 6" bung 22,4%, nhiem khuan da, mo mem 6,4%, nhiem khuan tiet nieu 4 , 6 % va nhiem khuan huyet 3,2%, SIRS 2,8%, nhiem khuan tieu hoa 1 , 1 % , nhiem khuan khong ro nguon goe chiem 12,4%. Nghien ciru VNRES tai eac khoa Hoi sdc ti'ch ci/c tai d cae benh vien Viet Nam cung ghi viem phoi chiem ti le eao nhat 7 8 % , nhiem k h i . " -la mo mem 5%, nhiem khuan tiet nieu 3 % v- nhiem khuan huyet 4 % [3]^ ECDC ghi nhan viem phoi 19,4%, nhiem khuan vet mo ciiiem '9,50/0 nhiem khuan du'dng tiet nieu 19,0°/. \>lr!.
Y HOC VIET NAM THANG 6 - S O 1/2015 khuan huyet 10,7% va nhiem khuan du'dng tieu
hda chiem 7,7% [ 4 ] . Mpt nghien cdu d Y 2013 ghi nhan viem phoi 77,5%, nhiem khuan huyet ehiem 1 4 , 1 % , nhiem khuan du'dng tiet nieu 8,4% [ 6 ] . Nghien edu d My 2012 eho thay viem phoi chiem 4 8 % , nhiem khuan du'dng tiet nieu chiem 37% [ 1 ] .
Ve tac nhan gay nhiem khuan benh vien, so sanh vdi mdt so nghien cdu khae, A.baumannii v i n la tac nhan chiem ti le eao nhat trong nhiem khuan benh vien tai khoa Hoi sdc tich cu'c, va ti le nay co the thay doi cao thap tiiy thupe vao cac nghien ciru khac nhau tai tdng ddn vi hoi sde khac nhau.
Bang 2/Tac nhan qay nil
Tac nhan A.baumannii Klebsiella spp S.areus P.aeruginosa Enterococcus spp
E.Coli Stenotrophomonas maltopiiilia
em kiiuan benh vien Gay nhiem Ichuan benh Chunq toi
53,9 12,1 8,8 7,7 6,1 3,3 3,3
VNRES[6]
31 18 6 12 6 6 1
vien (%) ECDC[41
3,6 8,7 12,3 8,9 9,6 15,9
Gay viem phoi thd may (%) CR[5]
61 10,4 11,7 11,7 5,2
CR[7]
55,7 13,2 8,79 15,1 1,9
Bing 3:X\n\\ hinh de khang carbapenem
A.baumanni P.aeruginosa
Khoa Hoi su'e tich cu'c BV Chd Ray Chung
toi 95,9%
71,7%
2009 [5]
Imipenem 80,9%
Meropenem 83%
Imipenem 44,4%
Meropenem 33,3%
2011[7]
Imipenem 84,7%
Meropenem 86,4%
VNRES [6]
79%
81,2%
ECDC [4]
16%
31,8%
V. K^TLUAN
Ti le nhiem khuan benh vien tai khoa Hoi sdc b'ch cdc - Benh vien Chi? Ray la 51%. Thdi gian bung binh xay ra nhiem khuan benh vien la 8 ngay. Viem phdi lien quan den thd may chiem ti le cao nhat 38%, tiep den la nhiem khuan 6 bung, nhiem khuan dddng tiet nieu, da va md mem. Tae nhan gay benh pho blen la Acinetobacter baumanii, Klebsiella spp va Pseudomonas aeruginosa. Ti le de khang cua Acinetobacter baumanii vdi Carbapenem la 95,9% va ciia Pseudomomas aeruginosa \h 71,1%.
TAI UgU THAM KHAO
1. Laurent M, Borres PN, Le Thuaut A, Liuu E, Ledudal K, Bastuju-Garin S, et al. (2012), "Impact of comorbidities on hospital-acquired infections in a geriatric rehabilitation unit: prospective study of 252 patients". J Am Med Dir Asscoc. 2012(00;
13(8): 760 7-12.
2. Phillip Dellinger R, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Henwig Gerlach, Steven M. Opal, et ai. (2013), "Surviving Sepsis Campaign: International Guidelines for
Management of Severe Sepsis and Septic Shock:
2012", Critical Care Medicine and Intensive Care Medicine, 4(5), 580-637.
Simonetti A, Ottaiano E, Daina M, Onza C, Tnasi M (2013 ), "Epidermiology of hospital-acquired infections in an aldult intensive care unit: Results of a prospective cohort study". Ann Ig. Jui-Aug;
25(4): 281-9.
The European center for diseases prevention and control (2013), "Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospital".
Vo Hu'u Ngoan (2010), "Nghien cdu tinh hinh viem phdi hen quan den thd may tai khoa san soc dac biet benh vien ChO Ray". Luan van Thac si Y hoc Dai hpc YDddc TP.HCM.
Vu Oinh Phu (2013), "Khao sat nhiem triing benh vien va sd dyng khang sinh tai khoa Hoi sde tich cu'c d Viet Nam". Bao cao hoi nghi tong ket VNRES
Vu Quynh Nga (2011), "Oac diem nhiem khuan Acinetobacter baumannii cl benh nhan viem phoi thd may tai khoa hoi sde cap edu Benh vien Chd Ray". Luan van Thac si Y hoc. Dai hoc Y Dddc TP.Ho Chf Minh.
