TAP CHf Y DUOC LAM SANG 108 Tap 12-56 5/2017
Tinh hinh su- dung khang sinh kinh nghiem va dk khang khang sinh 6* benh nhan viem phdi lien quan tho^ may
Characteristics of pneumonia and empiric antimicrobial therapy in ventilator-related pneumonia patients
TrSn Hihi ThSng*, *5g-„;j ^j-|„ g^^^^ j^^i Ng6 Due Ngoc** **Truang Dgi hgc YHa Ngi
Tomtit
Muc tiiu: D i n h gia tinh hinh sU dung khang sinh kinh nghiem va tinh trang de khang khIng sinh d benh nhan viem phdi lien quan thd mIy. Doi tuang vd phuang phdp: Nghien cUu md ta tren cac benh nhan viem phdi lien quan thd may du tieu chuan lUa chpn tai Khoa Cap cUu, Benh vien Bach Mai tU 1/2009 tdi 12/2013. Kit qud: Vi khuan A. baumannii chiem t / le cao nhat, 36 ca (49,3%), tiep theo la K. pneumoniae (11 ca, 15,1%), P. aeruginosa (8 ea, 11,0%). Ty le khIng khang sinh d nhdm nhiem A baumannn cao, chi trU coiistin. Kit ludn: A. baumannii thudng gap nhat trong viem phdi lien quan thd may. Tmh trang khang khang sinh d i n g io ngai. A baumannii va P. aeruginosa khang da sd cac loai khIng sinh trU coiistin.
Tdkhda: Vi^m phdi lien quan t h d may, khIng sinh, A. baumannn.
Summary
Objective: To evaluate the empiric antimicrobial therapy and antibiotic resistance in ventilator- related pneumonia patients. Subject and method: A descrictive study on ventilator-related pneumonia patients at the Emergency Department of Bach Mai Hospitai from January 2009 to December 2013.
Result: A. baumannn infection was the highest with 36 cases (49.3%), the second was K. pneumoniae (11 cases, 15.1%), and then P. oerag/nosa (8 cases, 11.0%). \r\ A. baumannii or P. aeruginosa infected patients, these bacteria were resistant to almost antibiotics. Conclusion: A. baumannii was the most common in ventilator-related pneumonia patients. Antibiotic resistance was dangerous with A baumanmi resistance to almost antibiotics, except coiistin.
Keywords: Ventilator-related pneumonia, antibiotics, A. baumannH.
I.Datvande sinh rat c l n thiet trong thUc hanh lam s i n g . SU dung
^.^ , , . , , . , . k h I n g sinh cdn rat bUa b l i v l sai nhieu. Tai Khoa Bien chung t h u o n g gap cua thong khi nhan tao ^ ^ , . „ „ . , . , „ , . . . , , . ; ,. .v ,. , , ^. ..T . . . ', , , .» , ., ,. . Cap CUu A9 Benh vien Bach Mai, hang ngay phai tiep la viem phoi. Nhiem trung benh vren hien nay la mot , . , , , , • , - ' , - , , - . - , .
... ^^ , .,. ^ • , • . • . , ^ ... nhan mot luong kha Idn benh nhan nang can thong van de y hoc nan g i l i , dUOc y hoc tren toan the giPi , , , ' , . ' , \ , , * , ' . , . , , , ,
, . . . , • , ; , , , ' - ^ . , -• khi nhan tao, nguy CP nhiem khuan benh vien kha quan tam. Day la mot benh ly lam gia tang dang ke .,.. " , , , . , , . , , ..' . ' ..^
, , , , , .' ' , ,r^^ . , , , , cao. Viec su dung khang sinh kinh nghiem eon nhieu t y l e t U v o n g va b e n h t a t , t a n g c h i phi dieu t n [1], [2], , '.. ^, ,' . . . . .. .., , , . . . . , , ' " ^ ^ . ^ ^ " , , . tranh cai. Chinh vi vay, chung toi tien hanh nghien I3J; VI vay nghien eUu dac diem va oieu t n khang , , ^ .. ' r^. , - . L I . . L . J
^ ^ CUu nham muc tieu Danh gia tinh hinh sU dung khdng sinh kinh nghiem vd tinh trgng de khdng khdng Ngdy nhdn bdL 20/2/2017. ngdy chap nhdn ddng: 10/4/2017 j / ^ ^ fj fj^nh nhdn viim phoi liin quan thd mdy.
Ngu&i phdn hdi: Ngo Due Ngoc,
[email protected] - TrudngD^i hpc YHa Npi
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY
2. Ddi t u o n g va pliUong p h a p
Nghien cUu dUpc tien hanh tai Khoa Cap cUu Benh vien Bach Mai Xii 1/2009 den 12/2013.
2.1. Doi tugng
Tiiu chuan lUa chon binh nhdn
Benh n h i n dUPe dat dng npi khf q u I n t h d may tren 48 gid.
Tiiu chuan logi trd
Benh n h i n cd bang chUng viem phdi tU trudc:
S d t , c d t h l m nhiem phdi..,
Tiiu chuan chdn dodn viim phoi Hen quan thd mdy (VPLQTM):
Benh nhan chan d o l n vi&m phdi lien quan t h d may khi ed day du 2 tieu chuan lam sang va vi sinh:
Chan doan lam sang: DUa theo b i n g diem l l m sang viem phdi CPIS cila Pugin: Benh nhan dugc chan 3. Ket quS
d o l n I I VPLQTM khi cd diem viem phdi > 6 sau thd m I y ft nhat 48 gid (khdng lay tieu chuan vi khuan).
C h i n doan vi sinh: Ket q u i nudi cay dich phe q u I n duong tfnh. Djch phe q u I n dupe lay b i n g dng hai ndng cd ndt b i o ve d I u xa qua phUdng phIp sol phe quan. Ket q u i dugc coi I I dUPng tfnh ed y nghia vdi ngUdng £ 10^ vi khuan/ml tUPng dUPng > 10'vi khuan/ml b&nh pham.
2.2. Phuang phdp
Thiet ke nghiin cu^: Nghien cUu can thiep tien cUu. Cd mau: Thuan tien.
Biin sd nghiin cdu: Tudi, gidi, benh ly nen, nguyen nhan dat npi khf q u I n , ^ e m APACHE \n^\e mac cac loai vi khuan gay viem phdi. CIc thuoc khang sinh, tinh hinh de khang va nhay cam.
Xdly sdliiu: Nhap dCf lieu, xUly va phan tich so lieu bang eae thuat toan thdng ke y hpc phu hop, mUey nghTa a = 0,05.
B i n g 1 . Dac d i e m v i e m ph6i li§n q u a n t l i d may Chls^
Ket q u i
Thcri gian xuat hien vigm phoi (ngay)
5,8 ± 3,3
Thdi gian t h d may (ngay) 7,5 ± 4,4
Thcri gian n I m ICU (ngay) 13,5 ±10,8
TuTvong lien quan t h d m d y
12,4%
W/idnxef; 63,6% vi khuln/C/efas/e//apneumon/a sinh men (J lactamase phd m d r d n g . Bang 2. Ket qua cay v i sinh dich ha t h a n h m o n
3 - 5 ngay (n = 56)
6 - 1 0 ngay (n = 33)
n - 1 5 ngay (n = 6)
Acinetobacter baumanmi (n, S 16(48,5%) 5 (83,3%)
Pseudomonasaeruginosa (n, %) 9(16,19f
Klebsiella pneumonia (n, 9i Escherichia coli (n, %)
Staphylococus aureus (n, '•. 2 (3,6%)
Serrratia marcescens (n, 5 2 (3,6%)
Burkholderia cepacia (n, %) 1 (1,8%) 3 (9,1%)
Streptococus pneumonia (n, 9 1 (3,0%)
Enterobacter cloacae (n, 5 4 (7,2%)
Streptococuss pneumonia (n, %) 3 (5,4%) Chryseobacterium
Meningosepticum (n, %) 2 (6,0%)
Ndm Candida (n, 9( 1 (16,7%)
TAP CHf Y Di;OC LAM SANG 108 Tap12-So 5/2017
Nhgn xet: Cay djch ha thanh mon cho thay gap nhieu loai vi khuan hon so vfli vi khuan gay viem phoi lien quan t h * may, t r o n g do co ca nam Candida. Chiem tj le cao nhat la Acinetobaaer baumannii, dac biet tir dich cay tir ngay t h i j 11 trcr di chi^m 83,3%. Loai vi khuan cay dupc tir djch tren cuff gap tiep theo la P.
aeruginosa va K. pneumonia.
So benh nhan VPLQTM do vi khu^n Klebsiella pneumonia sinh men ESBL: Co 63,6% vi khuan Klebsiella pneumonia sinh men p lactamase pho rong, gay khang v6i nhieu loai khang sinh.
a
m ESBLW • ESBLHBieu do 1. Vi khuan Gram am sinh men ESBL Nhgnxet: 63,6% vi khuan Klebsiella pneumonia sinh men p lactamase pho m d rpng.
Bdng 3. T$ Ig Si khdng khang sinh cija vi khuan gay VPLQTM
~ ~ ~ - ^ ^ ^ Vi khu^n
Khang sinh —.^...^
Ceftrlaxon Ceftazidime Cefotaxime Cefoperazone Cefepime Ampicillin + Sulbactam Piperacillin + Tazobactam Cefoperazone + Sulbactam Gentamycin
Amikacin Tobramycin Ciprofloxacine Levofloxacine Imipenem Meropenem Ertapenem
Tlcarcillin + Clavulanic acid
A. baumannii (n = 3 6 )
25 18,5
25 0 50 11,5 14,8 36,3 13,8 14,8 25 16 33,3 21,4 27,6
P. aeruginosa (n = 8)
33,3 0
20 0 33,3
60 60
83,3 80 83,3 83,3
K. pneumonia (n = 11)
33,3 33,3 33,3 50 28,6
28,6 28,6 14,3 42,9 14,3 14,3 33,3 75 75 83,3 33,4
E.coli (n = 5)
33,3 33,3 100
66,7
100 100 75 100 75 75 75 100 100 100 100
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N-5/2017
Nhgn xet TJ le nhay cam vdi khang sinh fi nhom A. baumannii la thap, duel 50% vdi tat cS cac loai khang sinh dupc SLT dung.
T^ le de khang khang sinh ciia vi k h u j n gay VPLQTM:
• Khang • Trung gtan • Nhay
90% - 80% - 70% - 50% - 40% - 30% ~ 20% - 10% -
~ -
: --
- "
-- -
- "
- --
/fW/XM^^4^yy^y
Bi^u do 2. T^ le de khang khang sinh cua Acinetobacter baumannH (n = 36)
Nhdn xet: Acinetobacter baumannii de k h I n g cao nhat doi vdi c l e nhom khang sinh cephalosporin, quinolone, carbapenem (75%), 100% k h I n g vdi cefoperazone, khang tr^n 80% doi vdi ampicillin + sulbactam va piperacillin + tazobactam, chi co Coiistin h o l n toan chua b| k h I n g .
• Nh^y • Tmng gian • Khing
B0%
60% H 40% - 20% •
c? / / ^ ^ / / / / / / /
Bieu do 3. Ty le di khang khang sinh cua Pseudomonas aeruginosa (n = 8)
Nhdn xet: Pseudomonas aeruginosa: Bi k h I n g cao nhat doi vdi k h I n g sinh ceftazidime, cefepime, ampicillin + sulbactam. Oe khang k h o i n g 40% - 50% doi vdi piperacillin + tazobactam, cefoperazol + sulbactam va aminoglyeosid. Con nhay vdi carbapenem.
TAP CHf Y D a o c L A M SANG 108 T a p 1 2 - S o 5/2017
• Nhsy • Tmng gian • Khing
SD%
/ / c / / / / . / / / / /
Bieud64.Ty led^khang khlngsinhcCia/('/efas/e//opneumon/a(n = 11)
Nhgn xit: Klebsiella pneumonia khang chO yeu vdi cephalosporin the h f 3, quinolone va aminoglyeosid.
Con nhay cam vdi piperacillin + tazobactam, cefoperazol + sulbactam, carbapenem.
• Tmng gian • Khdng
B i e u d o 5 . T y 1$ d e k h a n g k h a n g s i n h cCia Escherichia coH ( n = 5)
Nhdn xet Escherichia coil khang chu yeu vdi cephalosporin the he 3, quinolone v l aminoglyeosid. Con nhay d m vdi carbapenem.
/ c /
Bieu do 6. T^' le de khang khang sinh cCia Staphylococus aureus (n = 5).
JOURNALOF 108-CLINICALMEDICINE AND PHARMACY Vol.12-N''5/2017
Nhdn xit: Toan bp Staphylococus aureus deu khang methicillin, k h I n g toan bo p lactam, ke dt carbapenem, ehl nhay vdi vancomycin.
4. Ban luan
Khi so sanh vdi nghien cdu cua cle t i c g i l 6 chau Au va c h l u My, vi khuan Gram I m gay viem phoi lien quan t h d may ddng h I n g dau la P. aeruginosa, ft gap A baumannH [2]. Cac nghien cdu tai Viet Nam trddc d l y 10 nam cung cho thay vi khul'n P. aeruginosa gay viem phoi li^n quan t h d may chiem chu yeu. Theo Giang Thuc Anh (2004) VPLQTM chiem t J le cao n h l t I I A.baumannH 44%, P.aeruginosa 2 1 % , cle vi khuan khac I I Kpneumonio 13%, S.aureus 7% [3]. Nghien cdu chung toi cung eho thay, vi k h u l n Gram I m gap nhieu n h l t la A baumannH chiem gan 50%i. D l y cung la vi khuan thddng gap nhat g l y viem phoi lien quan thd may d chau A trong nhCfng nam g i n day, hien nay da trd thanh van de thdi sii doi vdi Viet Nam va cae nddc chau A [8].
Trong khi do, chung toi it gap S. aureus (chi ed 6,9%) so vdi cle nghien edu d chau Au, My S. aureus gap tren 20%) [2]. Nhdng t>' le m I c S. aureus trong nghien cdu chung toi tdong t d vdi nghien edu d An 0 6 , ThIi Lan [8]. Rat hiem gap vi khuan ky khf, n I m [6], c l n p h l i ed c l e ky thuat nudi eay d i e biet.
Chastre, ehi gap 0,9% nam g l y VPLQTM [2].
Ty li di khdng khdng sinh cua vi khuan gdy VPLQTM:
Khang khang sinh lam t i n g t^* le t d vong, thdi gian t h d may, thdi gian n I m vien cung nhd chi phf dieu tri cho benh nhan. Be giup eho cac b l e sy trong viec Ida chon khIng sinh hop \y va viec xuong thang khang sinh, viec lam khang sinh do de xac dinh vi khuan nhay cam hay de khIng vdi cle loai khIng sinh thddng dung rat quan trong. Trong nghien cdu, chung toi chf ban luan ty" le de khang khang sinh doi vdi cac loai vi khuan g l y viem phoi lien quan thd m I y I I A. baumannii, K. pneumonia, P. aeruginosa, E. coH va 5. aureus. Cac loai vl khuan con lai (S. marcescens, B. cepaciava S. pneumonia) do so lieu It nen chung toi khong ban luan. A bauman/iH khang lai nhieu loai khIng sinh thddng dung hien nay, khang 100% v a cefoperazole, ciprofloxacin khoing 80%, levofloxacin 70%. Dac biet, vdi nhdm khIng sinh manh, pho rpng carbapenem cLing khIng gan 70%; A
baumannH cung khIng tren 80% doi vdi ampicillin + sulbactam v l piperacillin + tazobactam.
Cach d l y 10 n I m >4. baumanH ehl chiem mpt t ^ ^ nho va con nhay nhieu vdi imipenem va cle khang sinh nhom aminoglyeosid [3]. Ben n I m 2008 d l xuat hien nhieu ehung A baumanii da khIng thudc, t^f l§
nhay vdi imipenem giam eon 45,2% va hau nhif k h I n g vdi amikacin. Nhan xet eua ehung tdi cQng t d d n g XU nghien cdu cua John [6]. L^ g i l i khi nang khang thuoc nhanh den nhd vay. CIc gia thiet cho rang chfnh nhd co sa di truyen gene khang khang sinh qua plasmid nen tdc dp di truyen nhanh vi co the dot bien ehi qua mpt the he sinh s i n , do vay ma ehi sau 2 - 3 nam Acinetobacter baumanH da cd the k h I n g toan bp vdi loai thuoc ma chung da nhay h o l n toan trddc day.
P. aeruginosa khIng vert cephalosporin III va carbapenem ngay mdt tang [1] qua viec sinh ra p- laetamase nguon gdc nhiem sac the AmpC P.
aeruginosa khang cao nhat vdi ceftriaxone, cefotaxime va ampicillin + sulbactam (gan 100%). Ket qua cua chung tdi cung tddng t d eua John [6] K. pneumonia con nhay e l m vdi carbapenem, tuy nhien de khIng gSn 40% doi vdi quinolone, aminoglyeosid. K pneumonia sinh men p lactamase m d rdng (ESBL +) khang tr§n 60% doi vdi khang sinh cephalosporin va chat dc che P lactamase. Nhan xet eua chung tdi tdong t d cCia John [6]. Trong khi do, £ coli nhay e l m vcfi hau h ^ khang sinh nhdm carbapenem, piperacillin + tazobactam- Tuy nhien khang gan 50% vdi ceftriaxone, ceftazidime, ampicillin + sulbactam, ciprofloxacin v l levofloxacin.
Nhan xet cua chdng toi khac vdi nghien cdu cCia John [6], £ coli di khang doi vdi cac loai khang sinh tren chifi tdi 20%. Cd tdi 50% trddng hop nhiim Staphylococcus oureus lien quan Khoa Hoi sde tfch cdc d My la cac chung khang methicillin [1] do vi khuan mang gen mecA, gen ma hda cho protein gan penicillin 2a. Trong nghien edu chung tdi, S. aureus deu khang vdi methicillin. Tuy nhien, do trong nghien cdu sd latJng benh n h i n m I c Staphylococcus aureus con it (chi 5 trddng hop), vi v l y can nghien cdu tiep vdi so Idong Idn hon trong tddng lai.
TAP CHf Y Daoc U M SANG 108 T^p12-S6 5/2017
5. Ket l u a n
Vi khuan Gram am chiem tren 90%, A. baumannii gap nhieu nhat, dieu nay khIc so vdi khu vdc chau Au v l My. A. baumannii khang vdi da so cle loai khang sinh trCr coiistin. P. aeruginosa khang cao nhat vdi ceftriaxone, cefotaxime va ampicillin + sulbactam (gin 100%). Klebsiella pneumonia cdn nhay e l m vdi carbapenem, tuy nhien de khIng gan 40% ddi vdi quinolone, aminoglyeosid. Escherichia coH nhay e l m vdi hau het khang sinh nhdm carbapenem, piperacillin + tazobaaam, tiearcillin + acid clavulanic, cefoperazone + sulbactam. Tuy nhien k h I n g gan 50%
ddi vdi ceftriaxone, ceftazidime va ampicillin + sulbaaam, ciprofloxacin va levofloxacin.
Staphylococcus aureus deu khang vdi methicillin, da so khang vdi khang sinh khac.
Tai lieu t h a m khao
1 American Thoracic Society (2005) Guidelines for the management of adults with Hospital-acquired, Ventilator-assosiated, and Healthcare-assosiated Pneumonia. Am J Respir Crit Care Med 153:388-416.
2. Chastre J and Jean-Yves F (2005) Vent/Vator- associated Pneumonia. American journal of respiratory and critical care medicine 165:867-903.
3. Vincent JL, Bihari DJ, Suter PM et al (1997) The prevalence pf nosocomial infection in intensive care unit in Europe Results ofthe European prevalence of inaction
in intensive care (EPIC) study. EPIC international advisory committee. Chest 112:458^5.
Giang Thuc Anh (2004) Nhdn xet tinh hlnh sd dung khdng sinh trong dieu tn nhiem khudn BV tgi Khoa
&TTC BVBgcb Mai2003 - 2004. Luan van tdt nghiep b l e sT noi tru, TrUdng Bai hpc Y Ha Npi.
Trjnh Van Dong (2005) Nghien cdu nhiem khudn ho hdp d binh nhdn chdn thuang so ndo phdi thd mdy.
Luan van tot nghiep Tien sy y di/pc, Trudng Bai h p c Y H I N p L
Jones RN (2010) Microbial etiologies of hospital- acquired bacterial pneumonia and ventilator- associated bacterial pneumonia. Clin Infect Dis 51(1): 81-87.
Marik PE, Careau P (1999) Vie role of anaerobes in patients with ventiiatorassociated pneumonia and aspiration pneumonia: A prospective study. Chest 115:178-183.
Chawla R (2008) Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries.
Am J Infect Control 36(4): 93-100.
Babcock HM et al (2003) Ventilator-Associated Pneumonia in a Multi-Hospital System: Differences in Microbiology by Location. Infect Control Hosp Epidemiol 24:853-858.
