Y HOC VIET NAM THANG 7 - SO 1/2012
edng la 6,4); ty le DSOH/10000 dan la 0,7 (tfnh rieng y te edng la 0,4).
Theo mdc dd tang dan so, giai doan 2012- 2015 can bd sung 73-95 BS va 68-72 DSOH.
Hoa Binh can ed cac bien phap quan ly va cae chfnh sach dai ngd thye te de thu hiit eac bae sT, dyde sT cd trinh do, chat lypng ve cdng tae tai eac ddn vi y te cdng. Xay dyng ke hoaeh dao tao va dao tao lai, dao tao nang cao can bd hien CO de giai quyet van de thieu hut va dap dng nhu cau den nam 2015.
TAI UEU THAM KHAO
1. Bo Noi vu - Bo Y te (2005), Thong tUlien tich so O8/2607/TTLT-BYT-BNV HUdng dan dmh mdc bien che sU nghiep trong cac cdsdy te nha nude
Bg Y te & nhom dol tac y te (2009), Nhan lUcy ted Viet Nam, Bao cao chung tong quan nganh y te nam 2009.
Nien giam thong ke tinh Hoa Binh (2010), Nha xuat ban thong ke,
Nguyen Hong Stfn (2008), Nghien cub thUc trang nguon nhan luc y, dUdc va dU bao nhu cau nhan iuc y, dUdc tai tinh Phu Tho giai doan 2010- 2015, Luan van thac sT du'dc hoc, TrUcJng Dai hoc duoc Ha N61.
Vo Van Tai (2009), ThUc trang nguon nhan lUc va mot sdyeu td lien quan den dong lUc iam viec cua bac si binh vien da khoa tinh Quang Ninh, nam 2009 - 2010, Luan van thac si quan ly benh vien, TrUdng Oat hoc Y te cong cong.
Tong cue thong ke (2011), DU bao dan so Viet Nam 2009-2049, Nha xuat ban Ha Noi, tr. 52.
DANH GIA MUfC DO DE KHANG KHANG SINH CUA CAC TAG NHAN GAY N H I I M TRUNG M A U TAI BENH VIEN BACH IVIAI - NAM 2011
Boan Mar Phu'dng*, Nguyen Quoc Anh*
TOM TAT
Nhiem trung mau la mot trong nhu'ng nguyen nhan chu yeu gay benh tat va iii vong. Xac dinh mire do de khang khang smh ciia vi khuan gay nhiem triing mau giup cac bac sy lam sang co hUcing dieu tn dung dan, han che ty le tir vong cho benh nhan. Muc tieu nghien cii'u: Oanh gia mire dp de khang khang sinh ciia cac VI khuan gay nhiem trung mau benh vien Bach Mai. DOI tu'dng va phu'dng phap nghien cii'u: 957 chiing vi khuan phan lap 6 benh nhan nhiem triing mau, ty 01/01/2011 den 31/12/2011, tai benh vien Bach Mai. Xac dinh mdc do de khang khang smh ciia vi khuan bang phu'dng phap khoanh giay khang smh khuech tan Kirby - Bauer. Ket qua dyde xir ly theo chUdng trinh WHONET 5.4. Ket qua va ket luan: Ty le E. coll de khang amoxicillin-Facid clavunalic la 28,6%; ceftazidime 48,4%; gentamicin 41,0%;
ciprofloxacin 46,6%; nhay cam v6i cac khang sinh earbapenem 100%; sinh ESBL [+]38,3%. Ty le K.
pneumoniae sinh ESBL [+] 13,7%. Ty le A, baumannii de khang ceftazidime 72,7%; earbapenem la 60,6%;
amikacin 65,6%; ciprofloxacin 66,7%; minocycline 9,1%; colisbn 6,7%; ty le toan khang (PDAB) 57,1%.
Ty le S. aureus khang methicilline (MRSA) 28,1%.
•* Benh vien Bach Mai
Phan bien khoa hgc: PGS.TS. Nguyen Gia Binh
ABSTRACTS
ANTIBIOTIC RESISTANCE IN BACTEREMIA AGENTS AT BACH MAI HOSPITAL, IN 2011 Bacteremia is one of the main reasons causing disease and death. Determine the rate of antibiotic resistance help doctors with the nght treatments, limit mortality for patients. The objectives: Assessing the antibiotic resistance of bacteria causing bacteremia at Baeh Mai hospital. Subjects and methods: 957 bactena strains isolated of sepbcemia patients, from 01/01/2011 to 31/12/2011, at Bach Mai hospital.
Determination of the antibiotic resistance by disk diffusion Kirby Bauer method. Results and conclusions: The rate of £ coll resistant to amoxicillin -i- clavunalic acid was 28.6%; to ceftazidime was 48.4%; to gentamicin was 41.0%; to ciprofloxadn was 46.6%; the rate of B. coli sensitive to carbapenems were 100%; ESBL [+] producing was 38.3%. The rate of K pneumoniae ESBL produced [-I-]
was 13.7%. The rate of A. baumannii resistant to ceftazidime was 72.7%, earbapenem was 60.6%;
amikacin was 65.6%, ciprofloxacin was 66.7%, minocycline was 9.1%, colistin was 6.7%. The rate of pan drug resistance A. baumannii (PDAQ) was 57.1%.
The rate of methicilline resistance 5. aureus (MRSA) was 28.1%.
Y HOC VIET NAM THANG 7 - SO 1/2012
I. O A T VAN OE
Nhiem triing mau la mdt trong nhdng nguyen nhan chii yeu gay benh tat va t d vong.
Trong nhffng thap ky vda qua, mac dii cd nhieu tien bd vydt bac trong hieu biet cd ehe benh sinh ciia nhiem triing mau eung nhy sy phat trien ciia eae phydng tien va ky thuat hdi sdc tich eye nhyng, ti le mac benh eung nhy ti le t y vong ngay cang tang cao. Sd ea nhiem triing mau mdi nam tren the gidi la khoang 18 trieu ca, tai Hoa ky khoang 1,3 tneu ca, Chau Au va Nhat la 1,9 tneu ca. Chi phi hang nam cho nhiem trimg mau tai Hoa ky la 16,7 b/_USD va chau Au la 6,7 ty USD. T d vong do nhiem triing mau tai Hoa ky ti le t y vong tang cao trong thap ky vya qua la 139%, sd ca t d vong hang nam la 400.000 ea.
Xae djnh myc dd de khang khang sinh eiia vi khuan gay nhiem trimg mau giiip cae bae sy lam sang cd hydng dieu tri diing dan, han che t^
le t d vong eho benh nhan.
Muc tieu ciia de tai nham: ^'Danh gia mdc do de khang khang sinh cua cac vl khuan gay nhiem trung mau tai benh vien Bach Mai".
II. OOI T U O N G VA PHUONG PHAP NGHIEN CUU 2 . 1 . Doi tu'dng nghien cu'u
- Vi khuan: 957 chiing vi khuan phan lap t d benh nhan nhiem triing mau
- Thdi gian nghien cdu: T d 01/01/2011 den 31/12/2011
Dia diem nghien cdu: Benh vien Bach Mai
2.2. Vat lieu nghien cu'u
Mdi trydng, smh pham, khoanh giay khang sinh ciia edng ty BioRad (Hoa ky) va Bio - Merieux (Phap).
2.3. Phu'dng phap nghien cu'u -Xac dinh mdc do de khang khang sinh ciia vi khuan bang phydng phap khoanh giay khang smh khueeh tan Kirby - Bauer. Ooc ket qua bang each do dydng kfnh vdng vd khuan tfnh ra milimet. oydng kfnh nay dyde chia thanh eae mdc do nhay cam - trung gian - de khang theo tieu chuan diem gay "breakpoints" hydng dan eiia CLSI - 2011 (Hoa ky).
- Ket qua dyde xii ly tren may vi tfnh theo chydng trinh WHONET 5.4.
III. KET QUA NGHIEN CCfU VA BAN LUAN 3 . 1 . Ket qua de khang khang sinh cua E. coli:
60 - - ^S''^
40 20 0
28,6 1 1
R " °
Bieu do 1. Ty le de khang khang sinh eua E. coli (n = 164) Ket qua d bleu do 1 cho thay, E. calico ty le
de khang cao vdi nhieu loai khang sinh khac nhau. Mire dp de khang amoxicillm-i-acid clavunalic cua E. coli la 28,6%, de khang cephalosporins the he 3 la 48,4%. Rieng cac khang sinh earbapenem, E. coli edn nhay cam 100%, chu'a xuat hien ehiing de khang. Odi vdi nhdm aminoglycosides, E. coli thu'dng de khang bang san xuat ra mdt sd men nhy acetyltransferase hay nucleotidyl transferase.
Trong nghien cdu nay, f . CD//da de khang tu'dng ddi cao vdi gentamicin 41,0%. Vdi nhdm fluoroquinolones ty le de khang la 46,6%.
Hien nay benh truyen nhiem do eae vi khuan da de khang khang sinh dang gia tang. Oe ton tai vi khuan gay benh ludn san sinh ra eac ed ehe de khang mdi, Hdn nffa, viee sd dung ngay eang tang va lam dung khang sinh hien cd eiia ngu'di dan va ciia can bd y te eung la nguyen nhan lam VI khuan gia tang de khang,
Y HOC VIET NAM THANG 7 • SO 1/2012 3.2. Ket qua xac djnh E. cativh K. pneumoniaes\nh ESBL [ Bang 1. Ty le E. coli va K. pneumoniae sinh ESBL f + l
Vi l<huan E co/;(n=164) K. pneumoniae (n=55) Tonq conq (n=219)
So lu'dng 56
8 54
H:
Ty le % 34,1 14,5 29,2 Ciing vdi F. coli va K. pneumoniae cac vi
khuan dydng rudt thudc ho Enterobacteriaceae cung dang ngay cang gia tang ty le de khang nhieu loai khang sinh thdng thydng. San sinh beta-lactamase la cd ehe chfnh de khang khang sinh ciia cac vi khuan nay. ESBL (extended spectrum beta-lactamase) la mdt loai beta- lactamase phd md rdng do vi khuan sinh ra, cd kha nang phan hiiy cac khang sinh nhdm beta- lactam, ke ca cae beta-lactam phd md rpng nhy cac cephalospotin the he 3, 4. Hien nay tren the gidi da phat hien ra hdn 400 loai ESBL, Cac ESBL cd ten la TEM, SHV, CTX-M, OXA, VEB, PER.., Kha nang san sinh ESBL lan truyen nhanh chdng giya cac vi khuan chii yeu qua trung gian R- plasmit. Khi vi khuan sinh ESBL [-I-] chung du'dc cdi la de khang toan bd cac khang sinh nhdm beta-lactam, ke ea eac beta-lactam hoat phd rdng nhy cephalosporin the he 3, 4 va
aztreonam. Cac vi khuan sinh ESBL [H-] thydng de khang cheo vdi nhdm quinolon va aminoglycoside, lam eho viee lya ehpn khang sinh dieu tri het sde khd khan. Cae khang sinh dypc ehi dinh dieu tri vi khuan sinh ESBL [-I-] la earbapenem nhy ertapenem hoac cac beta- lactam phdi hdp vdi chat iic ehe beta-lactamase nhy acid clavulanic, sulbactam hay tazobactam theo hydng dan eiia ket qua khang smh dd.
Do myc dp khang thudc nghiem trpng ciia cae vi khuan nay, nhieu tai lieu da dya ra khuyen cao trong viec phdng chdng lay nhiem ESBL la phai phat hien kjp thdi vi khuan sinh ESBL [-i-];
han che sd dung cephalosporin the he 3 khi ty le vi khuan smh ESBL [-f] tang cao; each ly hoac lyu y eae benh nhan mang hoae nhiem ESBL [ + ] ; giam sat nhiem khuan neu ed s y gia tang vi khuan sinh ESBL \+\
3.3. Ket qua de khang khang sinh cua A. baumannii:
6 5 , i r " „ , , .:„,:"",;« 7" ^6.7 ^ 5 , 5
n ,
^.1 6,/
1 1 1-1 7, \
i
1
1
.cS-
_.o<r ...4^
Bieu do 2. Ty le de khang khang sinh ciia A. baumannii (n= 35) Hien nay A. baumannii 6anq trd thanh mdt
trong nhUng nguyen nhan chfnh gay nhiem trung benh vien, Cac khang sinh chfnh dung de dieu tri nhiem khuan do A. baumannii la beta - lactam, aminoglycosides va fluoroquinolones. Tuy nhien, ty le de khang vdi khang sinh thdng dung trong nghien cdu nay deu cao tren 60,0%. Mot cephalosporins hang dau diing de dieu trj nhiem A. baumannii la ceftazidime da bi de khang lai vdi ty le 72,7%; de khang earbapenem la 60,6%.
A. baumannii 6Q khang ciprofloxacin va amikacin vdi ty le 65,7% va 65,6%. Trong nhdm khang sinh phdi hdp chat dc che beta-lactamase, ty le de khang ampieillin+sulbactam la 60,6%.
Ty le A. baumanniltoan khang (PDAB: pan dnjg resistance A. baumannii) nghla la khang vdi ^ t ca cae khang sinh thdng dyng rat eao vdi 57,1%.
Minocycline dype xem la cd tac dyng de dieu tri A. baumannii, trong nghien cyu nay ty le de khang la 9 , 1 % ,
68
Y HOC VIET NAM THANG 7 - SO 1/2012 Collstm dyde chi djnh trong trydng hdp vi
khuan da khang va toan khang, ty le A.
baumannii dk khang colistin thap vdi 6,7%. Can het sdc than trpng tru'dc khi s d dung vi colistin la
khang sinh cd dpc tfnh cao, khdng nen diing ddn le colistin ma nen phdi hdp vdi cac nhdm khang sinh khae nhy earbapenem, ddng thdi theo ddi thu'dng xuyen chdc nang than ciia benh nhan.
3.4. Ket qua de khang khang sinh cua S. aureus:
60 40 20 0
r^' <9' f^' <?' •?' ^' t^'
S^ # A-? . # .J.-*' , . / "^
28.1
9, 3,-
35.2 , , , , 31,4 , 4 ,
r~l ' r~\ lA n n
II , n II n V "
><? .^•^
Bieu do 3.1<y le de khang khang sinh ciia S. aureus (n= 130) Trong nghien eyu nay, ty le S. ai/re^ys khang
methicillin (MRSA: methlcillin resistant S. aureus) la 2 8 , 1 % . Ty le nay da tang len so vdi nam 2004 - 2005 la 15,4%, nam 2008 la 13,6%. S. aureus khang methlcillin dypc coi la de khang toan bo cac khang sinh nhdm beta-lactam, ke ca cac cephalosporins the he 3, earbapenem va beta- lactam phdi hdp chat dc che beta-lactamase.
Nhieu nghien cdu cung eho thay cd mot ty le Idn tu cau vang khang methlcillin la da de khang vdi cac khang sinh khac nhy gentamicin, azithromycin, ciprofloxacin, Vi vay, can phai cd sy giam sat chat ehe va cd chien lu'dc sd dung thudc phii hdp vi methicillin la thudc dieu tri hang dau cho nhiem khuan do tu cau vang va ft dpc hdn nhieu so vdi vancomycin.
Vancomycin la khang sinh dyde lya chon thay the khi benh nhan bj di dng vdi cae khang sinh nhdm beta-lactam hoac khi 5. aureus khang methicillin. Tuy nhien de phat hien S. aureus khang vancomycin phai tien hanh t h d nghiem xac djnh nong dp dc che tdi thieu MIC (minimal inhibitory concentration) theo hydng dan cua CLSI (Hoa Ky).
V. KET LUAN
1 . O e k h a n g ciia E coii
Ty le £. coli de khang amoxicillin+acid clavunalic 28,6%; ceftazidime 4 8 , 4 % ; gentamicin 41,0%; ciprofloxacin 46,6%.
- Odi vdi earbapenem, £ coli cdn nhay cam 100%, c h u ^ xuat hien chiing de khang.
- Ty le f . co/Zslnh ESBL [-I-] la 38,3%.
2. Oe khang cua K. pneumoniae:
Ty le K. pneumoniae smh ESBL [-i-] la 13,7%.
3. Oe k h a n g cua A. baumannii:
- Ty le A. baumannii de khang ceftazidime 72,7%; earbapenem la 60,6%; amikacin 65,6%;
ciprofloxacin 66,7%; minocycline 9,1%; colistin 6,7%.
- Ty le A. teumanniitoan khang (PDAB) 57,1%.
4 . Oe k h a n g cua S. aureus:
- Ty le 5. aureus khang methicilline (MRSA) 2 8 , 1 % .
Khdng thay ehung khang vancomycin.
TAI LIEU THAM KHAO
1. CLSI: Oinical and laboratory standard institute (2009). "Prindple and procedure Ox blood cultum".
Approved guldline M47 - Vol 36 - No 31.
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(2011) "F^ribrmance standards for antimicrobial did<
susceptibility tests". Approved standard - Ninth edihon.
I David Uvermore (2002),"Extended Spectwm Beta - Lactamase in resistancd' Clin Infect Dis; 34: 634-640.
5. Livermore DM (2002), "Pocked guide to Extended Spectrum Beta-Lactamase in resistance". Current Medicine group, London, UK.
6 The Sanford - Third Edition (2007). '''Guide to antimicrobial therapy".
7. WHO ( 2 0 0 2 ) " Global stratery for containment of antimicrobial resistance". Executive Summary.
