Y HOC VIET NAM THANG 5 - s6 oAc BI$T/2013
HIEU QUA CUA COUSTIN TRONG DIEU TR! NHIEM KHUAN BENH VIEN DO VI KHUAN GRAM AM DA KHANG TAI KHOA HOI SUfC TICH CUC NOI
BENH VIEN VllT TIEP HAI PHONG
Tran Thanh Cdng*, Bui Van Tam*
v^ tap thd BS khoa HSTC Npi
T O M TAT
Muc t i e u : €)anh gia hieu qua cua Colistin trong dieu tri nhiem khuan benh vien do vl khuan da khang. Phu'dng phap: 16 benh nhan nhiem khuan benh vien tai khoa HSTC Npi benh vien Viet Tiep Hai Phong tif thang 4/2012 den het thang 3/2013 phan lap du'dc vi khuan da khang khang smh nhuYig con nhay cam vcfi Colistin.
Ngay khi co ket qua khang sinh do benh nhan se du'dc su" dung Colistin theo phac do va di/dc danh gia dap utig vdi dieu t n sau 48 den 72 gid.
Ket qua: 16 benh nhan (14 nam, 2 nif), 9 tru'cJng hdp phan lap du'dc Acinetobacter chiem ty le 56,3%. 13 tru'dng hdp viem phoi benh vien chiem ty le 81,2%. Ty le tu' vong ngay thir 28 sau diing Colistin la 6/16 (37,5%), 5 benh nhan du'dc dieu tri phoi hdp Colistin vdi Imipenem va Doxycyclin cho ty le thanh cong cao 100%. Ty le dieu trj thanh cong theo tifng loai tac nhan gay benh Klebsiella, Pseudomonas va Acinetobacter lan Iu'dt la 100%, 66,7% va 55,6%. Chi gap 1 tru'dng hdp bj suy than tang len khi su" dung Colistin. Ket luan: Dieu tri Colistin trong tru'dng hdp nhiem khuan benh vien do vi khuan Gram am da khang co ty le t i i vong ngay thiT 28 la 37,5%. Phoi hdp Colistin vdi Imipenem va Doxycyclin cho ty le thanh cong 100%. Nhiem khuan benh vien do tri/c khuan mii xanh va Klebsiella da khang dap ii'ng vdi dieu tn Colistin tot hdn so vdl Acinetobacter. It gap tac dung phu khi dieu tri Colistin
SUMMARY
Objective: to evaluate the effects of Colistin in the treaments of nosocomial infections caused by pandrug resistant (PDR) Gram- negative bacteria. Methods: 16 patients with nosocomial infections caused by PDR Gram- negative bacteria at the medical ICU of Viet Tiep hospital from 4/2012 to 3/2013 were treated with intravenous Colistin. Results: the mortality rate was 37,5;9 cases caused by Acinetobacter (56,3%), 13 cases hospitalised acquired pneumonia (81,2%);5 patients were treated Colistin combine imipenem and doxycyclin are successfully 100%, only 1 case increased renal failure. Conclusions: Colistin treatment in nosocomial infections caused by PDR Gram- negative bacteria has the mortality rate 37,5%.
Combine Colistin with imipenem and doxycyclin for a 100% success rate. PDR Klebsiella and Pseudomonas respond to treatment Colistin better than Acinetobacter. The side effects of treatment Colistin was rarely.
I.
DAT VXN OENhidm khuan bdnh vien (NKBV) thirong xdy ra a cac khoa HSTC, noi didu tri nhidu benh nhdn (BN) tinh mang dang bi de dga lai thuang mdc nhidu benh man tinh, suy gidm midn dich va phai chiu nhidu thii thuat can thidp nhu tha may ho hdp ho trg dai ngdy, dat catheter, dat sonde tidu, cdc 6ng dan Ima, phdu thuat... Nghidn cim tai khoa HSTC
* Benh vien Viel Tiep
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Ngoai bdnh vi?n Vi$t Ti?p cho thay ty 1?
NKBV trong hai ndm 2009-2010 Id 15,8%, trong d6 chii yeu la viem ph6i do thdr mdy chiem 83,93% [2].
Tac nhan gay NKBV thu&ng gdp Id cdc trvrc khudn Gram am. Ciru song cdc BN ndy thirc sir Id thach thiJC ldn cho tal cd cac khoa HSTC, nhdt la khi mam benh Id cdc vi khuan khang nhieu khdng sinh. Hi?n nay, Colistin Id khdng sinh dugc hau het cdc tdc gid tren the gicfi lira chgn phoi hgp vai cdc khdng sinh khdc (khong diing dan dgc colistin) trong dieu In true khuan Gram dm da khang song chua c6 mgt Hirong dan didu trj nao dat dugc dong thudn vi bdng chung va so nghien ciru tin cdy dugc con it. De tim hieu dgc tinh, hidu qud dieu tri ciia Colistin chung toi tidn hanh nghien cuu ndy nham muc tieu:
Bdnh gid hieu qud cua Colislin trong dieu tri nhiem khudn benh vien do vi khudn Gram dm da khdng khdng sinh lgi khoa Hoi sue lich cue Ngi benh vien Viet-Tiep
II. 0 6 l TUONG VA PHUONG PHAP NGHIEN CUU
1. Doi tuong nghien ciiu
16 BN NKBV phdn lap dugc vi khudn da khang khang sinh nhung con nhay cdm vai Colistin dugc didu tri bdng Colistin tai khoa HSTC Noi benh vidn Viet Tiep Hai Phong tir thang 4/2012 ddn hdt thang 3/2013.
2. Phu-ong phap nghien cii-u Thidt ke nghien ciru: Mo ta tidn cuii Cach thuc tidn hanh: Cac bdnh phdm
(djch phe qudn, dich mdng ph6i, mdng bung, nudc tidu, ddu catheter tinh m^ch trung tam, mau) dugc ldy, giii soi tuai, nu6i cay tim mam b?nh vd ldm khang sinh d6 theo dirng quy trinh t^i khoa Vi sinh Viet-Tiep ngay khi BN m6i vao khoa HSTC ngi vd dugc chin dodn Id NKBV. Ngay khi khdng sinh d6 cho thdy vi khudn phdn lap dugc khdng hdu hdt khdng sinh, kd cd carbapenem vd con nhay cam vdi colistin thi colistin dugc sir dung phoi hgp theo phdc do; lidu diing cua colistin dugc tinh nhu sau:
Lidu n^p (mg dang base) = Cdich x 2 x trgng lugng ca the (kg)
Tong lieu duy tri/ngay (mg dang base) = Cdich X (1.5 xCLCr+30)
Bdnh nhan co CLCr duai 10 ml/phiit:
chia 2 lan/ngay
Bdnh nhdn co CLCr trdn 10 ml/phut:
chia 2-3 Idn/ngay
Trong do CLCr la do thanh thai creatinin ciia bdnh nhdn
Cdich Id nong do cua thuoc can dat duoc trong mau d trang thai on dinh (Cdich duoc cho la 1 mg/ml theo kinh nghiem ciia nhidu tdc gid va vi chiing loi chua cd dieu kien xac dinh MIC nong do uc chd tdi thidu).
Benh nhdn dugc danh gia ddp ung vcri didu tri sau 48 ddn 72 gid, theo ddi, thu thap cdc chi s6 nghien ciru hang ngdy thdng nhSt theo Bdnh dn nghien cim.
Xir ly sd lieu bdng phuang phap th6ng kd y hgc (sir dung phdn mdm SPSS 20.0).
III. KET QUA
1. Dac diem chung
Tir 4/2012 d6n thang 3/2013 co 16 BN NKBV do vi khuSn da khang nhimg con nhay cam voi CoHstin duoc dieu tri bang Colistin.
- Tu6i trung binh: 74,7 ± 7,4 (61-87)
- Gioi: 14 nam chigm 87,5% va 2 nu chiSm 12,5%
- Khoa chuySn benh nhan dSn:
Y Hpc VIET NAM THANG 5 • s 6 DAC BlgT/2013
C c A p HO T h A n T i m Y C i i N O i (--<'>'•• hAp K i n l i [Vl ^eh CTilii
<n=2> (n=4) ( i i ^ t t ) ( n = I ) <n=2) <n=l )
Khoa Hd hap cd 6 BN NKBV do vi khudn da khdng thudc chuydn HSTC Ngi chidm ty Id cao nhdt 37,5%.
- Lodi vi khudn da khdng:
(n-1)
o Acinetobacter baumanii
• Pseudomonas aeruginosa
56.3 • Klebsiella
Acinetobacter la tdc nhdn gdy bdnh chidm ty Id cao nhdt 56,3%
-Vi tri nhidm khudn:
1 2 . 5 {n=2)
• Viem ph6i
• Nhidm khuSn huydt
• Nhiim khuin catlieter
Vidm phdi bdnh vidn chiem ty le cao nhat 81,2%
- Xet nghidm thdi diem trudc khi sir dung Colistin Thonq so
Bach cau Creatinin mau
MLCT Protein mau Albumin mau
Nhom sonq (n=10) 16,8 ± 3,1 91,2 ± 10,0 48,4 ± 4,9 62,5 ± 2,2 28,9 ± 1,0
Nhom tir vonq (n=6) 18,9 ± 2,3 189,3 ± 98,6
50,0 ± 12,1 57,7 ± 2,3 28,1 ± 1,1
P
>0,05
<0,05
>0,05
>0,05
>0,05 Khdng cd sir khdc bidt cd y nghTa thdng kd ve bach cau, protein, albumin mdu, MLCT thdi diem trudc khi sir dung colistin
2. Hieu qua cua CoHstin
- Bdnh nhan: sdng 11/16 (68,8%), ndng xin vd 3/16 (18,8%), kien quydt xin vd khi chua didu trj dil phac do 2/16 (12,4%)
13
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- Ty Id tir vong ngay thii'28 sau diing colistin id 6/16 (37,5%) - Sd ngdy ndm vien va lidu Colistin
Ngay nam vien Nqay n i m tai HS Ngay thd mdy Ngay dieu trj colistin Lieu Coiistin/ngay
Song ( n = 1 0 ) 29,7 ± 3,6
12,3 ± 1,1 2,9 ± 0,2
Tur vong ( n = 6 ) 17,0 ± 5,6 14,8 ± 5,3 6,8 ± 2,3 2,3 ± 0,3
Khac bidl khdng cd y nghTa th6iig kd ve ngdy nam vien. ngdy thd may d hai nhdm song va tu \'ong
- Khang sinh plidi h(?p vdi Colistin
• sdng
• Ti> vong
Phdi hgp colistm vdi Imipenem va Doxycyclin cho ty Id thdnh cdng cao 100%
- Kdt qua theo loai vi khuan gay bdnh:
Kl>.-I>sjulln
NKBV do Pseudomonas va Klebsiella cd ty le didu tri thdnh cong cao han so vdi Acinetobacter
3. Tac dung phu Tac dung phu Ban di iTng Soc phan ve Suy than tanq len
So benh nhan T y le o/o
6 , 3 %
Chi gap 1 trudng hgp bi suy than tang len khi sir dung colistin _ 6 , 3 %
Y HOC Vier NAM THANG 5 - Sd OAC BieT/2013
IV. BAN LUAN
Dac diem chung: trong nghidn cim ndy, NKBV do vi khuan da khang chu ydu gdp d bdnh nhdn cao tudi (trdn 60 tuoi). nam nhidu hon ntt. Tudi cao. nghidn rugu.ca dia suy giam mien dich la cac yeu to nguy ca mac NKBV
BN nam didu trj tai khoa Hd hdp chuydn khoa HSTC Npi cd ty Id NKBV do vi khudn da khdng cao nhat chidm 37.5%. dieu ndy ciing phil hgp vdi t\ Id viem phdi benh vidn cao han nhidm khuan huyet va nhiem khuan catheter va cd le do cdc BN ndy bi cac bdnh phdi man tinh, da diing nhidu loai KS va vao vidn nhieu dgt, nam lau. gia yeu. Tdc nhdn gay NKBV da khdng thudc gap chu ydu la Acinetobacter chiem 56.3% ket qua nay cung phil hgp vdi nghien cuu ciia Medell tren 61 BN thd mdy thay rang Acinetobacter va true khuan mu xanh la nguyen nhdn chinh gdy bdnh [6]
Hidu qua ciia Colistin: Cd 11 BN sdng d thdi didm ra vidn nhung cd 1 BN sau dd tu vong do bdnh ndn ndn ty Id tu vong d ngay thiir 28 sau khi sir dung Colistin Id 37,5%
(6/16), thdp han nhidu so vdi ty Id tu vong do NKBV khong dugc didu tri bang Colistin cung tai khoa chiing tdi nam 2009-2010 la 65.45%[1]. Nghien cuu ciia Falagas trdn 28 BN NKBV do vi khuan da khang thu6c tai Hy Lap dugc didu tri bang Colistin cung cd ty le tir vong tuang ducmg la 41,7% [3 ]. Ty Id tu vong trong nghidn ciru cua chiing tdi cao han nghidn cuu ciia Huang Id 20%[4]. So ngay nam vidn, ngdy nam tai khoa Hdi sire, ngay thd may va sd ngay dieu tri Colistin giua nhom sdng va nhdm tir vong khdc bidt khong CO y nghia (p>0.05) cd le do sd BN cua mdi nhdm cdn qud nhd. Lidu colistin trung binh d nhdm sdng Id 2,9 (2 ddn 4) tridu dan vi/ngdy, d nhdm tir vong la 2,3 (1 ddn 3)
tridu dan vi/ngdy. Lidu ndy thap han so vdi khuydn cao ciia cac tdc gid nudc ngodi cd thd do chiing tdi chua linh dugc MIC nen coi nhu Cdich bang I mg/ml.Gdn day, mgt sd tac gid My, Nga dd nghj diing lieu colistin cao han nu'a de giam li I? khdng colistin va do colistin it dgc han da ludng, day cung Id mdt y kien ddng quan tam Irong thuc hdnh hang ngay vd can dugc nghien cim them.
Khdng sinh phdi hgp vdi Colislin: 5 BN dugc phdi hgp colislin vdi Imipenem va Doxycyclin ddu song chidm 100%. 4 BN phoi hgp colistin vdi Meropenem va Vancomycin song 3 (75%). Phdi hgp Colistin vdi Tazocin, Sulperazon cho kdt qua tir vong cao (67,7% vd 100%).
NKBV do true khudn mil xanh vd Klebsiella da khang ddp ung tdt ban vdi Colistin (ty Id sdng Id 66.7% va 100%) so vdi do Acinetobacter (ty le sdng thap hon chi co 55,6%), tuy nhidn do sd lugng BN d tirng nhdm it nen khdc bidt khdng co y nghTa Ihdng kd.
Chiing ldi khdng gap trudng hgp ndo bi soc phdn vd, cd 1 BN bi ndi ban di img sau khi diing Colislin nhung tu hdt khong can phai dimg thudc chdng dj irng, 1 BN suy than nang Idn khi diing Colistin nhung sau khi giam lieu colislin thi muc Igc cau than ciia BN nay da phuc hdi sau 7 ngay. Tasbakan dieu tri Colistin bang dudng tTnh mach cho 9 BN vidm phdi benh vidn do vi khudn da khdng chi gap 1 Irudng hgp thudc cd ddc linh vdi than [7]. Lidia Iruyen lieu cao Colistin cho cac BN NKBV do vi khudn da khang khong gap irudng hgp nao co tdc dung phu [5].
V. KET LUAN
1. Ty Id lir vong ngay Ihu 28 d nhdm BN nhidm khudn benh vidn do vi khudn Gram
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dm da khdng dugc dieu trj Colistin phdi hgp vdi cdc KS khdc Id 37,5%.
2. Phdi hgp Colistin vdi Imipenem vd Doxycyclin dieu irj nhiem khuan b?nh vi?n do vi khuan da khdng cho ly 1? thdnh cdng cao.
3. Nhiem khuan bi;iili vi(?n do tryc khuan mu xanh va Klebsiella da khdng ddp urng vdi didu tri Colislin lot hon so vdi Acinetobacter.
4. il gdp tac dyng phy khi dieu irj Colistin
TAI UEU THAM K H A O
I Ngo Thj Di^u Thuy (2011), "Mgl so nh^n xet ve linh trgng nhiem kluuiii Acinetobacter va Pseudomonas aeruginosa tgi khoa Hoi sue tich c\rc Npi b^nh vi?n Vi^t Ti?p Hai Phong trong 2 nam 2009-2010", Y HQC Vi^l Nam Ihdng 10 so dac bi('t/2011 tr 101-106.
2. Ngu>cn Thdng Toan va CS (2011),
"Nghien cuu tinli hinh nhiem khuan b?nh vien tai khoa Hoi sire Ngoai benh vien Vict Tiep Hai Phong trong 2 ndm 2009-2010". Y hoc Viet Nam thdng 10 .sd dgc biet/2011 tr 232-235.
3. Falagas ME, Rafalidis PI, et al (2008),
"Pand rug-resistant Klebsiella pneumoniae, Pseudomonas aeruginosa
and Acinetobacter baumannii infections:
characteristics and outcome in a series of 28 patients", Jnt J Antimicrob Agents. 2008 Nov;32(5):450-4. doi: 10.10.
Huang J, Tang VQ, Sun JY (2010),
"Intravenous colistin sulfate: a rarely used form of polymyxin E for the irealmenl of severe mu It idrug-resi slant Gram-negativa bacterial mfectwns", ScancIJ Infect Dis im Apr;42(4):260-5. doi: 10.
Lidia D, Filomena P et al (2012), "High- Dose, Extended-Interval Colistio Administration in Critically ill patients: Is this the right dosing strategy? A preliminary study" Majorariicle. CID 2012 54 (I Sjune).
Medell M, Hart M et al (2012), "Clinical and microbiological characterization of pneumonia in mechanically ventilated patients", Braz J Infect Dis 2012 Sep- Oct;16(5);442-7, doi: 10.10.
Tasbakan MS, Pullukcu H et al (2009),
"Colislin use in venlilalor-associaled pneumonia due to panresistani Pseudomonas aeruginosa
and Acinetobacter baumannii". Mikrobiyol BH/2009 Jan;43(l):61-70
