VIETNAM MEDICAL JOURNAL N°2 - OCTOBER - 2017
HIEU QUA CIIA HAI CHE DO LIEU SU" DUNG COLISTIN TRUYEN TINH MACH TRONG DIEU TRI VIEM PHOI LIEN QUAN THd" MAY
Nguyen Ba Cu-frng', Nguyen Hoang Anh^, Dao Xuan Cw', Do Thi Hdng Gam\ Dang Qu6c TuSn'
TOM TAT
Muc tieu: danh gia hieu qua ciia hai che do lieu sLf dung coiistin truyen tinh mach trong dieu tri viem phoi 'lien quan thd may (VPLQTM). Phu'dng phap:
nghien ciru tren 87 tru'dng hdp VPLQTM du'dc dieu tri coiistin tai khoa hoi su'c tich cLfc benh vien Bach Mai tir thang 9/2015 den 8/2017, cac benh nhan dUOc phan ngau nhien vao 2 nhom; 1 nhom sir dung coiistin che do lieu hien hanh (lieu A) va 1 nhom sir dung che dp lieu dieu chinh (lieu B). Ket qua: che do lieu coiistin dieu chinh (lieu B) dat hieu qua iam sang va vi sinh tot hon so vdi che dd tieu coiistin hien hanh (lieu A) (73,9% va 47,8% so vdi 53.7% 27,3%), t / le xuat hien ton thu'dng than gap d ca 2 che do lieu ia tu'dng diidng nhau (19,2% va 21.4%). Ket luan: che dp lieu B cho ket qua dieu tn tot hdn che do lieu A, ton thu'dng than la tu'dng difong nhau giu'a hai lieu.
Tir khoa: viem phoi lien quan thd may, coiistin.
SUMMARY
EFFECT OF TWO DOSAGE INTRAVENOUS COLISTIN REGIME I N THE TREATMENT OF
VENTILATOR -ASSOCIATED PNEUMONIA Objective: to evaluate the efficacy of two dosage intravenous coiistin regimee in the treatment of Ventilator-Associated Pneumonia (VAP). Methods:
the study included 87 patients with VAP treated at Intensive Care Unit of Bach Mai hospital from 9/2016 to 8/2017. Patients were randomized into 2 groups:
One group treated by the current dosage coiistin regimen (dose A) and one group treated by the adjusted dosage coiistin regimen (dose B). Results:
the adjusted dosage coiistin regimen (dose B) had better in clinical and bacterial responsed than the current dosage coiistin regimen (dose A) (73,9% and 47,8%, compare to 53.7% and 27,3%), acute kidney injury was the equivalent of two dosage regimen (19,2% in dose A and 21.4% m dose B).
Conclusions: the adjusted dosage coiistin regimen (dose 8) had better effectiveness than the current dosage coiistin regimen (dose A). Acute kidney injury was the equivalent of two dosage regimen.
Keywords.' Ventilator-Associated Pneumonia (VAP), coiistin.
I. OAT VAN DE
Coiistin du'dc phat hien dau tien nam 1940 va
^Benh viin Bach Mai
^Trddng Dal hoc Dddc Ha Ngi Chiu trach nhiem chinh: Oao Xuan Cd Email: [email protected] Ngay nhan bai: 14.7.2017 Ngay phan bien khoa hoc: 28.9.2017 Ngay duyet bai: 5.10.2017
bi cam sif dyng tir' nam 1970 do xuat hien dpc tinh tren than. Thudc nay du'dc siT dung lai gin day_vdi vai trd la vij khi eudi cimg trong dieu tri nhiem khuan gram am da khang. Nam 2012,' nghien ciTu chiTng minh che dp lieu trung binh tif 4-6 MUI/ngay {lieu du'dc tinh vdi nong dp dc ciie tdi thieu (MIC) ciia A.baumannii vdi coiistin la 0,25) dat hieu qua cao [1],_ nghien ciTu cung ghi nhan that bai vdi vi khuan cd MIC tren 0,38 [jg/ml[l]. Trong khi do, gia tri I^ICgo tich luy tk nam 2012 - 2015 la 0,5tjg/ml, dac biet nam 2014 MIC90 la 0,75tJg/ml [ 2 ] . Tuy nhien, che dp lieu cao lai di kem vdi lo ngai ve gia tang nguy cdton thydiig than[5],[6].
Trong bdi canh nhu' vay, mot che dp lieu coiistin toi u'u dam bao hieu qua dieu tri, can bang vdi nguy cd ton thu'dng than van dang la cau hdi Idn. Chung tdi de xuat mot che dp iieu coiistin dieu chinh, che dp lieu nay du'dc xay dyng tren eong thu'c tinh lieu ciia Garonzik, nhuYig diTdc tinh vdi MIC cua A.baumannii v6i coiistin la 0,5 [4]. Do dd, chiing tdi tien hanh nghien ciTu vdi muc tieu danh gia hieu qua va tj"
le xuat hien td'n thu'dng than ciia hai che dp lieu sir dyng coiistin trong dieu tri VPLQTM.
II. BOI TU'DNG VA PHU'DNG PHAP NGHIEN CUll 2 . 1 . Dol tu'dng nghien cu'u
Tieu chuan chpn BN: Benh nhan du'dc chan doan VPLQTM theo tieu chuan eiia IDSA 2016, ed ehi dinh dung coiistin, tren 18 tudi.
Tieu cliuan loai truT:
-Phu nii' cd thai, benh nhan diing colistjn trong vong 2 tuan tru'dc thdi diem vao nghien cdu, diing coiistin khdng du 72h, hoac thay doi
lieu trong vdn^ 72h. ^ -Tieu chuan loai trir danh gia xuat hien ton
thydngthan:
o Benh nhan Ipc mau khdng do nguyen nh§n suy than.
o Bgnh nhan suy than cap trdde khi sir dung cotistin.
2.2. Phu'dng phap nghien cu'u -Nghien cdu lam sang can thiep tai khoa Hoi sii'c tich cu'c - Benh vien Bach Mai tu" thang
9/2016 den 8/2017.
- Tieu ehuan chi dinh dung coiistin:^
o Oieu trj dac hieu: cay ra vi khuan chi nhay cam vdi coiistin.
94
TAP CHi Y HOC VIET NAM TAP 459 - T H A N G 10 - 5 0 2 - 2017
oOieu tri kinh nghiem; VPLQTM muon (tinh trang viem phoi xay ra sau khi dat dng NKQ va thd may > 5 ngay).
-Oe cu'dng nghien ciTu da du'dc Hpi dong dao dire Benh vien Bach Mai thdng qua.
-Cac benh nhan du'dc chia ngau nhien vao 2 nhdm: 1 nhdm sir dung coiistin che dp lieu hien hanh (lieu A) va 1 nhdm sir dyng che dp lieu dieu chinh (lieu B).
Lieu a - lieu hien hanh Lieu nap tinh theo can nang
<40kq
>40kg-50kg
>50kq-70kq Tren 70 kq
2 mui 3 mui 4 mui 5 mui
Lieu duy tri theo chu'c nang than Cier < 30 ml/phiit
CIcr: 30-50 ml/phiit Cler: 50-70 ml/phiit CIcr: 70-90 ml/phiit Cler > 90 ml/phut Loc mau ngat quang (hd)
Loc mau lien tuc ( c w h )
2 mui mdi 24 qid 1.5 mui mdi 12 qid
2 mui mdi 12 gid 2.5 mui moi 12 gid
2 mui mdi 8 qid 2 mui moi 24 gid 2 mui moi 8 gid
Lieu b ~ liieu dieu chinh Lieu nap tinh theo can nang
<30kq
>30kg-40kg
>40kg-50kg
>50kq-60kq
>60kq-70kq Tren 70 kg
4 mui 5 mui 6 mui 7 mui 8 mui 9 mui Lieu duy tri theo chu'c nang than Cler < 15 ml/phiit
Cler: 15-30 ml/phiit CIcr: 30-50 ml/phiit CIcr: 50-80 ml/phiit Cler > 80 ml/phiit Loe mau ngat quang
(hd) Lpc mau lien tyc (cwh)
3 mui mdi 24 qid 2 mui mdi 12 qid 3 mui mdi 12 gid 4 mui mdi 12 gid 3 mui mdi 8 qid 2 mui mdi 24 gid, bd
sunq Imui sau loc 3 mui mdi 8 gid 2.3. Chi tieu n g h i i n cu'u
- Oac diem mau nghien ciTu: gidi, tudi, can nang, chieu cao, BMI, mire do nang theo thang diem APACHE H, SOFA, CPIS, diem benh ly mac kem Charlson, benh ly nguyen nhan, tenh ly nen.
- Hieu qua lam sang:
o cd dap li'ng: Trieu chirng cai thien
• Nhiet dp cai thien + djch phe quan trong hdn va it hdn. Va
• Proealcinin giam > 80% hoac tu" 0.25pg/L - 0.5Mg/L.
oThat bai: Trieu chirng lam sang khdng thay doi hoac nang hdn:
• Procaicitonin giam < 80%.
• Sot khdng cai thien hoac sot cao hdn, djch tiet phe quan khong thay ddi.
- Hieu qua vi sinh:
) Oda vao ket qua cay ddm tai ngay 3, 7, va khi ra vien. Lay ddm qua catheter hut ddm, djnh danh vi khuan bang may Phoenix, nudi cay theo phu'dng phap ban dinh lu'dng, xet nghiem MIC eua A.baumannii vdi coiistin.
- Ty le xuat hien ton thu'dng than: dy'a theo tieu chuan RIFLE. Ton thypng than dydc dinh nghTa la tang nong dp creatinin huyet thanh tren 1,5 lan hoac mufc loc cau than (GFR) giam tren 25% so vdi gia tri tai thdi diem tru'dc khi bat dau diing thudc, duy tri it nhat trong 24 gid va xay ra sau ft nhat 2 ngay diing coiistin. Tinh CrCI theo cdng thirc Cockcroft- Gault,
2.4. Phu'dng phap xu* ly so lieu: Cae sd lieu du'dc phan tich theo phu'dng phap thdng ke y hpc.
III. KET QUA
3 . 1 . Dac diem cua mau nghien cu'u Bang 1. Bac diem chung aia mau nghien cii'u
Tuoi (nam) Gicfi (nam) Can nanq (kg)
BMI ( k q / m ' l Oiem SOFA Biem APACHE I I
Diem Charison Diem CPIS Creatinin nqav 0 I^LTC loc cau than nqav 0 Biiirubin toan plian nqav 0
Aibumin nqay 0
Nhom A (n = 4 1 ) 60.0 ± 20.7
27 (67.5) 58.6 ± 11.1
22.0 ± 3.3 5 [ 3 - 7 1 16.2 ± 5.3
iro-31
8 r 6 . 2 5 - 9 . / b ! 71.5 r55.75-94.751
77.9 ± 28.3 17 r 9 . 3 - 3 3 . 1 1
26.7 ± 5.0
N h b m B ( n = 4 6 ) 52.8 ± 16.3
32 (72.7) 60.2 ± 12.6
22.5 ± 3.8 6 [5 - 10]
16.1 ± 6.2 1 8
0 - 2 1 7 - 9 1 77 [69 - 129]
69.1 ± 40.0 22 [11.8 - 34.5]
29.1 ± 4.8
P 0.078 0.601 0.529 0.507 0.085 0.949 0.365 0.183 0.077 0.362 0.332 0.105
VIETNAM MEDICAL JOURNAL N°2 - OCTOBER - 2017 Thdi gian flieu tri tai khoa tru'dc
khi sir dung coiistin (nqay) Vi khuan Acinetobacter baumannii(%)
Klebsiella pneumoniae (%) Pseudomonas aerusinosa (%}
5 [2.25 - 7.0]
22 (55.0) 6 (15.0) 5 (12.5)
4.5 [2 - 6.25]
24 (54.5) 7 (15.9) 4(9.1)
0.967 O.908 0.730 Nhin xet: Phan bd ve tudi, gidi, can nang,
chi S O ' B M I , mii'c dd suy da tang (SOFA), diem mire dd nang (APA'CHE I I ) , diem benh ly man tinh (Charison) va thdi gian dieu tri tai khoa tru'dc khi diing coiistin tu'dng du'dng nhau.
- Vdi nhij'ng benh nhan danh gia xuat hien ton thu'dng than, dac diem ve nong dp creatinin
Bing 2. Hieu qui lim sang
mau, albumin mau, bilirubin mau toan phan la tu'dng du'dng nhau.
- Vi khuan chii yeu du'dc cay ra la A.baumannii, va t / le cay ra vi khuan giii'a hai nhdm la khdng cd su" khac biet.
3.2. Danh gia hieu qua tam sang
Nhom A(n = 4 1 ) I Nhom Bfn = 467 Ty le CO dap iTng lam sang (%) 22 (53.7) 32 (73.9)
Thdi gian thd may (ngay) Thdi gian thd may sau khi dung Coiistin (ngay)
11 [8 - 15] 9 [6 - 13]
5 [4 - 8] 5 [2 - 9]
Thdi qian nam tai ICU (ngay) 15.4 ± 6.5
Nhin xet Hieu qua lam sang eiia che dp lieu B tot hdn lieu A. Thdi gian thd may, thdi gian thii may sau khi dung coiistin va thdi gian nam tai khoa hoi sire tich ciTc khdng khac biet.
3.3. Danh gia hieu qua vi sinh Bing 3. Hieu qua vi sinh
i . - -
TV le thanh conq ve vi sinh (%) Mu'c 6o dap
utig Vi sinh
Hoan toan Dai danq B6I nhiem nhav cam
Ket qua nqhien cu'u Nhom A (n = 2 2 )
6 (27.3) 6 (27.3) 14 (63.6) 2(9.1)
Nhom B (n = 23) 11 (47.8) 11 (47.8) 12 (52.2) 0 ( 0 )
P 0.155 0.165 Nhin xet: Co 22/41 (53.7%) tru'dng hdp d nhdm A va 23/46 (50%) tru'dng hdp d nhdm vi khuan. Ty le thanh cdng ve vi sinh eiia phac do B va phac do A tu'dng du'dng nhau.
3.4. Danh gia ty le xuat hien td'n thu'dng t h i n Bang 4. Ty le xuSt Men ton thu'dng thin
Bcayra
Nhom A (n = 2 6 ) Nhom B [n = 28) Benh nhan xuat hien ton thu'dng than; n (%) 5(19-2) 6 (21.4) Thdi gian khdi phat tdn thu'dng than (ngay) 4.0 ± 2.10 Thdi glan nong dp creatinin cao nhat (nqay) 4 [ 3 - 7 . 5 ] 5.5 r2.75 -12.25]
Phan loai mu'c dd tdn thu'dng than; n (%)
Nguy cd - R Tdn thu'dng - 1
1 (20.0) 3 (60.0)
1 (16.7) 5 (83.3) than; n (%) | Suy - F j 1 (20.0) | OJUJ [
Nh^nxet'Jy le xuat hien ton thu'dng than, ngay khdi phat ton thu'dng than va ngay cd creatinine mau cao nhat cua hai nhdm la tu'dng du'dng nhau.
IV. BAN LU&N
Ket qua nghien cult nhan thay phac dd coiistin lieu dieu chinh (lieu B) dat hieu qua dieu trj tot, cu the: 73.9% benh nhan cd dap irng lam sang, 47.8% benh nhan dap iTng vi sinh va 21.4% benh nhan xuat hien ton thu'dng than.
Trong khi dd, che dp lieu hien hanh (lieu A) dat hieu qua thap hdn: 53.7% benh nhan ed dap li'ng lam sang, 27,3% benh nhan dap irng vi sinh va 19.2% benh nhan xuat hien ton thu'dng than.
Ty le dap uYig lam sang trong nghien cdu cua Dafino khi diing coiistin lieu 9MUI la 82%, va trong nghien ojfu cua Bui "Thi Hao la 70.5% [2] tu'dng
du'dng vdi hieu qua lam sang cua lieu B (73.9%).
Trong nghien cu'u nay, ty le dap dr\g vi sinli ciia ca hai lieu deu thap hdn so vdi cac nghien ciru khac. Nghien ciTu cua Bui Thj Hao, ty ledap irng vi sinh dat tdi 70.5%, cdn nghien ciCu ciia Nguyen Gia Binh dat 62.5%. Tren the gidl, vfl nghien ciTu cua Gu! R.Yilma thi t / le nay la 62,5%. Sir khac biet nay la do eac nghien ciiu tren danh gia tren cac benh nhan nhiem khuan tir tat ca cac nguon khac nhau (phoi, mau, djch o bung...) ed the lay lai benh pham de danh gia d^p dng vi sinh. Trong nghien ciru eua ehung toi chi danh gia tren nhuTig benh nhan VPLQTM,
TAP CHI Y HOC VIET NAM TAP 459 - THANG 10 - SO 2 - 2017 khd khan trong viec lay lai benh pham, dac biet
la nhij'ng benh nhan da rut ong npi khi quan.
Ti le xuat hien tdn thu'dng tren trong nghien ciru eiia chung tdi lieu A la 19,2% va lieu B la 21.4% tu'dng tu" nhu" nghien cu'u cua Dafino da cdng bd 18% [7] va cua Du'dng Thanh Hal la 22,9% [3].
Han che eiia nghien cuU la c3 mau tu'dng ddi nhd. Tuy nhien day la nghien CU^J lam sang dau tien so sanh hieu qua giu'a hai che dp lieu, dinh hu'dng cho thu'c hanh lam sang.
V. KET LUJSkN
Ket qua eua nghien cu'u ehung tdi nhan thay phac do coiistin lieu dieu chinh (lieu B) ed hieu qua cao hdn phac do lieu coiistin hien hanh (lieu A) trong dieu tri nhiem khuan benh vien do eac chimg Gram am da khang, tdn thu'dng tren than cua hai lieu la tu'dng td nhau va tu'dng ty" cac nghien cu'u da cdng bd tru'dc dd. NhuYig ket qua nay la cd sd de ap dung jphac do coiistin iieu dieu chinh trong dieu t n nhiem khuan nang.
Can tien hanh them nghien ciru vdi sd lu'dng benh nhan nhieu hdn va trong thdi gian dai hdn.
TAI LIEU T H A M KHAO
1. Binh Ng, Hayakawa K, Co Dxl, Tuan Nd, Anh Nh, Thuy Nt, Phuong Dm, Huong Nt, Thuy Pth, Chau Nq, Nhung Ph, Gam DoTh, Hai Dt, Huong Tt, Van
Anh L, Takeshita N, Ohmagari N, (2015), "Efficacy and nephrotoxicity asscociated with coiistin use in an intensive care unit in Vietnam: Use of coiistin in a population of lower body weight". International journal of infectious diseases, 35, pp. 18-23.
. Bui Thj Hao (2016). Phan tich hieu gua va ton thddng tren than cua coiistin che do lieu cao tren benh nhan nhiem trung benh vien tai khoa Hoi siit tich cdc Benh vien Bach mai, tap chi y hoc Viet Nam tip 441 T4, tr36-43.
. Du'dng Thanh Hai (2016), Nghien cub ton thddng than tren binh nhan sd dung coiistin tai khoa HOI sdc tich cdc Benh vien Bach Mai, Tap chi y hoc Viet Nam tap 441 T4, tri20-133.
. Bergen P. J., Bulitta J. B., Forrest A., Tsuji B. T., Ll J., Nation R, L. (2010), "Pharmacokinetic/
pharmacodynamic investigation of coiistin against Pseudomonasaeruginosa using an in vitro model", Anhmicrob Agents Chemother, 54(9), pp. 3783-9.
:. Omrani A. S., Alfahad W. A., Shoukri M. M., Baadani A. M., Aidalbahi S., Almitwazi A. A., Albarrak A. M. (2015), "High dose intravenous collsdn methanesulfonate therapy is associated with high rates of nephrotoxicity; a prospective cohort study from Saudi Arabia", Ann Clin Microbiol Antimicrob, 14, pp. 3.
I. Shahbazi F., Dashti-Khavidald S. (2015),
"Coiistin: efficacy and safety In different popu!aticmi\
Expert Rev Oin Pharmacol, 8(4), pp. 423-48.
'. Dalfino L, Puntillo F, Mosca A, et 3\.High-dose, extended-interval coiistin administration in critically ill patients: is this the right dosing ^lategy? A preliminary shJdy. Clin Infed Dis 2012;54(12):1720-6
DANH GlA KET QUA DIEU-TRI UNG THU* PHOI KHONG TE B A O N H 6 GIAI DOAN IV BANG PHAC DO PACLITAXEL - CISPLATIN
T A I B E N H VIEN D A K H O A TiNH THANH HOA
Hoang Thi H a \ Pham C^m PhuoTig^ Le Van Quang^
T O M TAT
Muc tieu: Danh gia dap irng va l i e dung khong mong muon ciia phac__do Paclltaxe! - Cisplatin tren benh nhan ung thu" phdi giai doan IV. Phu'dng phap nghien cihi: Md ta, hoi cu\j, tren 65 benh nhan ung thu' phoi khong te bao nhd giai doan IV du'dc dieu tri phac do paelitaxel - cisplatin. Ket qua: Tuoi trung binh la 61,82; Dap ifng cd nang 53,9%; Dap irng thu'c the 27,7%, khdng cd dap iTnq hoan toan, benh q\d nguyen 46,2%, benh tien trien 25,2%; Co moi lien quan giira sd chu ky hda chat vdi dap irng dieu trj vdt p=0.021< 0,05; Khong cd mdi lien quan giu'a lieu
'Benh vien Da khoa tinh Thanh Hoa
^Benh vien Bach Mai
^Trddng Dai hoc YHa Ngi Chiu trach nhiSm chinh: Hoang Thj Ha Emaii: [email protected] Ngay nhan bai; 12.8.2017 Ngay phan bien khoa hoc: 4.10.2017 Ngay duyet bai: 10.10.2017
thuoc va dap im^^ dieu tn vdi p=0,054 ; Tac dung phu tren he tao huyet gap kha cao nhuTig chii yeu do 1, 2:
Ty le ha bach cau 50,8%, ha bach cau hat 49,2%, co 2 trirdng hop ha do 4; Giam huyet sac td ehiem 49,2%, khdng cd tru'dng hop nao giam do 3 va 4;
Giam tieu cau chiem 12,3% chi giam dp 1 va 2.Ket luan: Phac do Paelitaxel - Cisplatin dem lai hieu qua va doc tinh chap nhan du'dc nen du'dc ap dung rong rai trong dieu tri UTPKTBNgiai doan hen xa.
Tu'khoa: Phac do Paelitaxel -Cisplatin. ung did phoi khong tebao nho.
SUMMARY
EVALUATING THE RESULTS OF PACLITAXEL - a S P U T I N REGIMEN I N TTIE TREATMENT FOR IV-STAGE NON-SMALL CELL LUNG CANCER AT
THANH HOA GENERAL HOPITAL Objectives: Evaluating the response and side effects of Paelitaxel - Cisplantin regimen in the treatment for IV-stage non-small cell lung cancer.
Methods: Retrospective, descriptivestudy on 65
