Y Hpc TP. Hb Chi Minh * Tap 21 * So 2 * 2017 Nghien ciru Y hpc
KHAO SAT DAC DIEM LAM SANG VA DE KHANG KHANG SINH CUA ACINETOBACTER BAUMANNII GAY VIEM PHOI BENH VIEN, VIEM PHOI T H 6 M A Y T A I KHOA HO HAP BENH VIEN CHO RAY
Duong Mitih Nggc*, Trdn Vdn Nggc**
TOMTAT
Dqt van de vd m^c tieu nghien ciiu: A. baumannii Id mot trong nhung tdc nhan chinh gdy viim phoi benh vien, de khdng vbi nhiiu khdng sinh thubng dung, gay khb khan trong chgn lua khdng sinh han dau. Muc tieu nghien deu: khdo sdt dqc diem lam sdng vd de khdng khdng sinh cua A. baumannii gdy viim phoi benh vim vd viim phm thb mdy tqi khoa ho h^ benh vien Chg Ray.
Doi tugng va phuong phdp nghien cim: Ld mgi nghiin cieu cdt ngang mo td vbi doi tugng la nhieng benh nhan dugc chdn dodn mim phoi lien quan chdm soc y te, viim phm binh viin vd viim phoi thb mdy do vi klmdn A. baumannii tqi khoa ngi ho hSJ3 binh viin Chg Ray tie thdng 10/2014 din thdng 04/2015.
Ket qud vd phdt hiin chinh: cb 36 binh nhdn nam trong tong so 60 benh nhdn dugc dua vdo nghiin cieu, tudi trung Mnh la 67,8. Hau hU benh nhan co cdc yeii to nguy ca cua viem phoi vd nhiim khuan da khdng thuoc.
Ti liA. baumannii khdng imipenem la 93,3%>, meropenem 95%o, cefoperazone/sulbaciam Id S6,7°/o, levofloxadn vd dprc^oxadn 98,3%, gentamidn 91J°/o, doxycyclin 45%>, rifampidn 8,3%,, colistin 0%. Ti li tie vong do mgi nguyin nhan Id 36,7%>.
Kei ludn vd kim nghj: Viim phoi lien quan chdm soc y te, viim phoi binh viin vd viim phoi thb mdy do A.
baumannii thubng xdy ra trin binh nhdn nam, Ibn turn, cb ii li tie vong cao. A.baumannii khdng v&i Kdu hii cdc khdng sinh pho rang thubng dung. Xem xet phoi hgp khdng sinh ngay tie ddu khi nghi ngb nhiim A. baumannii vd cdn nhac diing colistin dedieu tri.
Tie khoa: HCAP, HAP, VAP, A. baumannii ABSTRACT
INVESTIGATING THE CLINICAL AND RESISTANT ANTIBIOTICS FEATURES OF A.BAUMANNII CAUSING HOSPTTAL-ACQUIRED, VENTILATOR-ASSOCM.TED PNEUMONIA
IN RESPIRATORY DEPARTMENT OF CHORAY HOSPTTAL
Duong Minh Ngoc, Tran Van Ngoc
* Y Hoc TP. Ho Chi Minh * Vol. 21 - No 2 - 2017: 21 - 25 Background-Objectives: As a pathogen causing hospital-acquired and ventilatar-asssodated pneumonia, A.baumannii resists many antibiotics, and complicates efforts to choose primary antibiotics.
Objective:Investigating the clinical and resistant antibiotics features of A.baumannil
Materials and method: a descriptive and cross-sectional study. All patients with HCAP, HAP and VAP caused by A. baumannii in Respiratory Department of Cho Ray hospital from 10/2014 to 04/2015.
Results: 36 of 60 patients is male, and mean of age is 67.8. A.baumannii resists 93.3%, of imipenem, 95%o of meropenem, 56.7%o of cefbperazone/sulbadam, 98.3%o of levofloxadn and ciprofloxadn, 91.7%> of gentamidn, 45%o of doxycyclin, 8.3%o of rifampidn and 0%o of colistin. All-cause mortality is 36.7%o.
* Bp mon Npi, Dai hpc Y Dugc TPHCM " Khoa Ho hap, Benh vien Chg Ray
Tdc gid lien lac. ThS BS. Duong Minh Ngpc DT: 0975199100 Emaih [email protected]
N g h i e n c i ^ Y hpc Y Hpc TP. Ho Chi Minh » T^p 21 * So 2 ' 2017
Conclusioiv A.baumanniiresists many broad-spectrum antibiotics. Antibiotics must be combined to combat infections caused by A.baumannii and considered to use colistin in treatment this pathogen.
Key words: HCAP, HAP, VAP, A. baumannii.
D A T V A N D E
Viem phoi benh vien la nhiem trung benh vien thudng gap nhat, trong dd, A. baumannii la mpt trong nhimg tac nhan chinh ngoai P.aeruginosa, Klebsiella spp. va S. aureus khang methidllin, ti le tii vong chung thay doi tu 33- 45,5%'*'^'"*. Cac nghien cuu tir nhieu vimg mien Idiac nhau trong ca nude cho thay A. baumannii da khang vdi nhieu khang sinh thudng dimg, ke ca cac khang sinh pho rdng'^. Do dd, viec chpn lua khang sinh ban dau theo kinh nghiem trd nen khd khan va phiic tap hon. Hudng dan chon lua khang sinh ban dau theo kinh nghiem de dieu tri viem phoi benh vi?n, viem phoi tiid may cua IDSA/ATS 2005 cd le khdng cdn phii hpp vdi tinh hinh A. baumannii da khang thuoc d nude ta.
Vay nen, nghien ciiu dac diem vi sinh hoc tai cho ludn Ctin tiuet de cung cap cho bac sT lam sang thdng tin can thiet ve linh hinh de khang khang sinh ciia cac vi khuah thudng gap, tir do ra quyet djnh chpn lua khang sinh ban dau cho phu hpp, gdp phan giam thieu ganh ngng chi phi cham sdc y te. Do do, chung tdi ti&i hanh khao sat cac d|c diem de khang khang sinh cua A. baumannii gay viem phdi benh vien va viem phoi thd may tai khoa hd hap benh vien Chp Ray trong thdi gian tii thang 10/2014 doi 04/2015.
DdlTUtJNG-PHUtiNGPHAPNGEBENClJtJ Thiet ke nghien cuu
Md ta, cat ngang, tiai ciiu.
Doi t u ^ g n g ^ ^ n curu
Benh nhan dupe chah doan viem phoi lien quan cham soc y te^ viem phoi benh vien va viem phdi thd may do vi khuah A. Baumannii tai khoa noi hd hap benh vien Chp Ray.
Tieu chuan chon mau
Benh nhan dupe ehan doan viem phoi lien quan cham soc y te, viem phdi benh vien va
viem phdi thd may, cd ket qua cay dinh lupng chat tiet tCr dudng hd hap dudi duong tinh vdi A.
baumannii va dat nguong dupe xem la tac nhan gay benh.
Tieu chuan loai trii
Nhiing benh nhan cd mau chat tiet tCr dudng hd hap dudi khong dupe eay dinh lupng, hay duoc cay dinh lupng nhung khdng dat ngudng vi khuan gay benh, benh nhan xin ve sdm trudc khi cd ket qua dieu tri va benh nhan khdng dong y tham gia nghien ciiu.
Comlu
60 benh nhan thda tieu chuan chpn mau dupe dua vao nghien cihi, ttf tiiang 10/2014 deh 04/2015.
Fhuong phap tien hanh
Benh nhan thda tieu chuan chpn mau se dupe tiiu thap thdng tin ve dieu tri khang sinh 6 tuyen dudi, benh dong mac, yeu td nguy ca viem phdi, kham, ket qua sinh hda, X quang phdi, ve vi sinh gom cd ten, so luang vi khuan va khang sinh do, du lieu ve dieu tri gom khang sinh dupe dimg trudc va khang sinh dupe doi sau khi cd ket qua vi sinh, chia ket qua dfeu tri thanh 2 nhdm: sdng sdt-xuat vien va tii vong- xuat nang (vdi tien lupng tii vong). Nhap lieu va xii ly sd tieu bang phan mem SPSS 16.0. Su khac biet dupe xem la cd y nghia thdng ke khi p < 0,05.
KET QUA
Bdng 1. Ddc dian chung ve ldm sdng D^ctinh Gioi (nam' nO)
Tuoi
Yeu t6 nguy ccy viem phoi
va nhiem khuan da
Nam vi?n tip tuyen tnrac Ditng thuoc khSng tiet Dung khang sinh di/cmg Cnh
mgch a tuyen tm-crc B|it thdng mui dg day Dung corticoid Nlm vi|n > 2 ngdy/3 th^ng
tnroc
3:2 67,8 ±17,6
91,7%
88,3%
73,3%
63.3%
55.0%
51.7%
22
Y Hpc TP. Hb Chi M i n h * Tap 21 * So 2 * 2017 Nghien cuu Y hpc E)$c tinh
Thffi gian
Ketcgc
Tho miy, d|t npi khi quan tii tuy^n du^i Thdi gian nam vien ^ n g binh Tho^ gian tii IOc nhgp vi^n d^n khi cay ra A. baumannii
Tli vong chung
40.0%
22,7 ± 13,9 (ng^y) 9,57 ±6,53
(ngSy) 36.7%
Bang 2. Sii' dung Ididng sinh ban dau Tll^sipdi^ng khang sinh ban
a i u Theo ATS Theo khang sinh do
Phil h9p 76,7%
13.3%
Khdng phii hep 23,3%
86,7%
Bang 3. Ti li tie vong a 2 nhbm binh nhdn dung khdng sinh ban ddu
T i l f b j vong Khang sinh t)an dau theo ATS Khang sinh ban dau theo l(hang
sinh do
Phil h w 43,9%
0%
Khdng phiihg^
21,1%
42,3%
P 0,061 0,022 Bang 4. Ti li de khdng khdng sinh
[Oidng sinh Ticarciiitn-Clavuianic Piperacillin-Tazobactam Cefoperazone-Sulbadam
CefEazidime Cefepim Meropenem
imipenem Ciprofloxacin LewMaiadn Gentamicin Doxycydin Trimethoprim/SulfanieUioxazDie
Colisb'n
Ti 1% khing 95,0%
98,3%
56,7%
100,0%
96,7%
95,0%
93,3%
98.3%
98.3%
91,7%
45,0%
66,7%
0%
BAN LUAN
Ket qua (Bang 1) cho thay, 60% benh nhan tiong nghien ciiu la nam, dp tudi trung binh la 67,8. Ket qua nay tuong tu cac nghien ciiu khac cua tac gja Cao Xuan Minh'^', Dd Dinh Tuah'^) tien ddi tupng benh nhan viem phd'i do A.
baumannii, va tuong tu nghien ciiu tien benh nhan viem phdi do tac nhan khac nhu P.
Aeruginosa^ hay S. aureus*^.
91,7% benh nhan dupe chuyen d a i tir tuyai trudc, 73,3% da dupe dimg khang sinh dudng tihh mach, 88,3% dupe dimg thudc khang tiet (khang thu the H? va lic ehe bom proton) tiong
thdi gian nam vien, 63,3% dupe dat thong miii da day, 51,7% co tien sti nam vien > 2 ngay tiong 3 thang trudc, 55% faenh nhan dupe dimg corticoid dang hit trong thai gian dai. Cac nghien ciiu trude day cho thay sii dung thuoc khang tief"i, dat sonde miii da day<"' hay dimg corticoid dang hitP^* la nhung yeu to nguy co ciia viem phdi. Va hau het benh nhan eo cae yeu to nguy eo nhiem khuan da khang thuoc.
Thdi gian nam vien trung binh trude khi eay ra A.baumannii tiieo nghien ciiu cua Baran va cdng su la 20,8 ngay*^', tuy nhien, nghien ciiu cua chung tdi chi la 9,57 ngay. Khac biet nay cd the do lay nhiem cheo khi nam vien bdi vi each ly benh nhan nhiem khulm da khang thuoc khdng duoc tdt va dieu kien ve sinh khdng dam bao.
Ngoai ra, do A. Baumannii cd kha nang de khang vdi cac chat tay nia va diet khuan thdng thudng, nen vi khuan ed the sdng sot va cu tni khap mpi noi trong mdi trudng benh vien'^'"'.
Ve sii dung khang sinh theo kinh nghiem ban dau de dieu tri viem phdi, chiing tdi thay rang, ti Ie dimg khang sinh ban dau flieo hudng dan eiia IDSA/ATS la 76,7%, nhtmg sau khi cd ket qua khang sinh do, su phii hpp vdi khang sinh do chi dat 13,3%. Sd di cd ket qua nay la vi A.baumannii da de khang vdi hau het vdi cac khang sinh hien dang dimg.
Ti le tu vong do mpi nguyen nhan d benh nhan viem phdi do A. baumannii theo nghien ciiu ciia chung tdi la 36,7%, tuong tu nhu ket qua dupe ghi nhan trong cac nghien ctiu khae. Su khac biet ve ti Ie tii vong d 2 nhdm benh nhan dimg khang sinh ban dau phii hpp va khong phii hpp vdi hudng dan eiia IDSA/ATS khdng cd f nghia thdng ke (p = 0,061). Nhung ti le tii vong d 2 nhdm benh nhan duoc dimg khang sinh ban dau phii hpp va khdng phii hpp vdi ket qua khang sinh do la khae biet cd y nghia thong ke (p
= 0,022). Tuy nhien, Iy gjai ket qua nay phai than trgng do co mau cua nghien ciiu nay nhd, khdng dai dien het cho quan tiie benh nhan viem phoi do A. baumannii.
23
N g h i e n c u u Y hpc Y H p c TP. H o CW M i n h * T^p 21 * So 2 * 2017
D e k h a n g k h a n g sinh
De khdng nhom p-lactam, p-lactatn/iic chep- lactatnase vd carbapenem
Ti le de khang ceftazidime va cefepim tiong nghien ciiu nay lan lupt la 100% va 96,7%, vdi MIC >64 mg/L (theo tieu chuan ciia CLSI 2012). Ti le de khang lan lupt 98,3% va 56,7% vdi piperaciliin/tazobactam (PIP/TA2) va eefoperazone/sulbactam (CEF/SUL). Ti le de khang vdi imipenem la 93,3% va meropenem la 95%.
So vdi nghien eiiu cua Cao Xuan MirJi nam 2009, ti le khang vdi ceftazidime 88,11%, PIP/TAZ 67,13%, CEF/SUL 3,5%, imipenem 58,74% va meropenem 57,34%'*'. Nhu vay, ed flie thay ti le A. baumannii khang nhanh chdng vdi cac khang sinh nhdm p-Iactam, p- lactam/iic che p-lactamase va carbapenem chi trong vdng 5 nam-
Day la nhiing khang sinh cd hieu qua diet khuMi tdi da khi %T/MIC > 40%(5). Do dd, neu meropenem dimg lieu Ig x 3 (TIM) mdi 8 gid se dat hieu qua diet khuan chi khi MIC cua vi khuah tii 0,12-2 mcg/mLi^i. A baumannii trong nghien ciiu naykhang meropenem vdi MIC > 16 mg/L, do vay, viec dimg meropenem don dpc se khdng the dat hieu qua mong mudn. Day la mpt trong cae Iy do de sii dung ket hpp cac khang sinh khac nhau nham dat dupe hieu qua hiep dong giua eae khang sinh, lam giam MIC doi vdi timg khang sinh rieng le.
Nghien ciiu cua tac gia Pham Himg Van cho thay nhiing trudng hpp A. baumannii khang meropenem cimg nhu imipenem, khi ket hpp vdi colistin se giiip chuyen A.
baumannii tii dang khang imipenem va meropenem sang nhay vdi 2 khang sinh nay.
Cu the, colistin d nong dp 0,5 mcg/mL, 75%
trudng hpp tir khang meropenem tid thanh nhgy vdi meropenem va 73% ddi vdi imipenem''^. Dieu nay eiing dupe chiing minh tiong nghien ciiu ciia tae gia Pongpech, hieu qua hiep dong dat dupe khi ket hop imipenem
+ cotistin la 100%, meropenem+ colistin + sulbactamla 96,7%, meropenem + sulbactam 70% va 53,3% khi ket hpp sulbactam + colistin'"*. Tuy nhien, nghien ciiu tren thuc nghiem, tac gia Yilmaz cho thay, khdng cai thien dang ke dap iing lam sang, vi sinh, dpc tinh tren than, flidi gian nam vien va ti le ttr vong khi so sanh giiia cac nhdm benh nhan dupe dimg coUstin don tii, colistin phoi hpp sulbactam va colistin phoi hpp carbapenem'^'.
Be khdng nhom quinolone, aminoglycoside Ti Ie khang levofloxacin va ciprofloxacin trong nghien ciiu eiia ehung tdi la 98,3%. Ti le khang vdi levofloxacin va ciprofloxacin theo Cao Xuan Minh (2009) Ian lupt la 48,95% va 84,62%'fl, tuy nhien tiong mdt nghien ciiu khac cua Vii Quynh Nga (2011), ti le khang eiia ciprofloxacin da la 98,3%'^i. Cd tiie thay rang ti le khang vdi ciprofloxacin van giii d miic cao va ti Ie khang vdi levofloxacin tang dan theo Ihdi gian.
Ti le khang gentamicin trong nghien ciiu ciia chiing tdi la 91,7%, ti le nay khong bien ddng nhieu qua ihdi gian khi so sanh vdi cac nghien ciiu trudc do nhu ciia Vu Quynh Nga (2011)<^', Cao Xuan Muih (2009)'*', ti le khang gentamicin Ian luot la 96,6% va 87,4%. Thue te, day la nhdm khang sinh dupe dimg khong nhieu, ehi chiem 10% trong so cac khang sinh dupe chpn lua ban dau.
De khdng nhom tetracycline vd TMP/SMX Ti le khang vdi doxycyclin la 45% va TMP/SMX la 66,7% tiieo khang sinh do. Day la 2 khang sinh trong so it khang sinh cdn nhay cam vdi A. baumannii. Tuy nhien, day ehi la ket qua in vitro, chua chiing minh dupe lieu cd hieu qua in vivo hay khdng va cd le can phai nghien eiiu tiiem de xac dinh hieu qua ciia 2 khang sinh nay ddi vdi berih nhan viem phoi do A.baumannii.
De khdng colistin
Tuong tu nhu n ^ e n ciiu cua Vu Quynh Nga trude day'^', ehiing tdi khdng ghi nhan A.
baumannii khang colistin trong nghien criu nay.
Day la dieu dang mimg khi cdn mdt khang sinh
Y H g c TP. H o Chi Minh * T | p 21 * So 2 * 2017 Nghien cthi Y hgc
nhay cam tdi 100%. Tuy nhien, nhieu nghien ciiu trade day aia cac tac gja trong nude da dio thay A. baumannii khang colistin vdi ti le thay ddi tir 1,4% tdi 55,6%'*'i^"'2i), dieu nay cung tuong tu nhu cac nghien ctiu ngoai nudc'''*''^'. Day thuc su la mdt dieu dang lo ngai.
KET LUAN VA KIEN NGHI
Viem phdi lien quzm cham soe y te, viem phdi benh vien va viem phdi thd may do A.
baumannii thudng xay ra tien doi tupng benh nhan nam, ldn tuoi va cd ti le tii vong cao. A.
baumannii phan ldn da khang vdi hau het cac khang sinh phd rpng tiiudng dimg. Chua ghi nhan de khang vdi colistin. Viec phoi hpp khang sinh dieu trj ngay tir dau khi nghi ngd nhiem A.
baumannii la mpt lua chpn hpp ly, va can nhac sii dung colistin theo lieu da dupe nghien ciiu vdi cac nguyen tac ve dupe luc.
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Ngdy nhdn bdi bdo- 21/11/2016 Ngdy phdn bien nhqn xet bdi bdo: 01/12/2016 Ngdy bdi bdo dugc ddng: 01/03/2017
