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Nghien cihi mirc do khang khang sinh cua cac chung vi khuan phan lap duac tai dau catheter tmh mach duoi don 0^ benh nhan chan thuotig so nao, dot quy nao
Research the degree of antibiotic resistance of bacteria at the distal tip of the subclavicular venous catheter in the patients with head injury and stroke
Tran Dac Ti§p*, *Benh vien Qudny 103 -Hoc vien Qudny Dang Anh Son** **BSnh vien J 98 Hd Noi
Muc tiiu: Phln lap vi khuan va nghien eUu mUe dp khIng khIng sinh ciia cle chung vi khuan phan lap dupe tai dau trong catheter dat d tTnh mach dudi ddn. Doi tugng va phuong phdp: Nghien cQu tien eUu, md ta d 61 benh nhan dat catheter tinh mach dudi ddn, tai Khoa Dieu tri tich cue Benh vien 198 H I Npi tU 11/2014 den 7/2015. Ket qud; C l n nguyen g l y ra nhiem khuan dau trong catheter ehii yeu la eac true khuan gram am (60%), trong do Abaumanii 20%; Kpneumonia 20%; P.aeruginosa 13,3% v l Enterobacter 6,7%; eac eau khuan gram dUdng (40%) trong do S.epidermidis 26,7% va S.aureus ehiem X^
le thap hdn 13,3%. Khdng t h I y n h i i m n I m . CIc chiing vi khuan phan lap dupe cd ty le de khIng cao vdi mdt sd khang sinh: Cau khuan gram duong khang hau het vdi cle khang sinh thdng dung nhU:
Amplcillin/sulbactam, penicillin, tobramycine, ceftriaxone. ChUa thay chiing staphylococus nao khang vdi vancomycin; true khuan gram am khang khang sinh rat cao, chi cdn nhay cam vdi nhdm carbapenem, coiistin va piperaeillin/tazobaetam. Kit lugn: Cae vi khuan khang thudc rat cao. Clu khuan gram dUOng cdn nhay e l m tdt vdi vancomycin, true khuan gram I m cdn nhay cam vdi nhdm carbapenem, coiistin va piperaeillin/tazobaetam.
Tdkhod: Catheter, vi khuan, gram dUdng, gram I m , khIng sinh, khang khang sinh.
Summary
Objective: Classifying bacteria and researching the degree of antibiotic resistance of bacteria at the distal tip of the subclavicular venous catheter. Subject and method: A descriptive, prospective study was conducted in 61 patients w/ith the subclavicular venous catheter at ICU, Hospital 198, Ha Noi from November 2014 to July 2015. Result The majority of bacteria at the distal tip of the catheter were negative bacilli (60%), including A.baumanii (20%); K.pneumonia (20%); P.aeruginosa (13.3%) and Enterobacter(6.7%); positive cocci (40%), including S.epidermidis (26.7%) and S.aureus (13.3%). No fungal infection was recorded. Bacteria had a high proportion of antibiotic resistance: Positive cocci resist almost all common antibiotics such as ampicillin, penicillin, tobramycine, ceftriaxone; negative bacilli resist most antibiotics, only sensitive to carbapenem group, coiistin and piperaeillin/tazobaetam.
Conclusion: Bacteria have an extremely high proportion of antibiotic resistance. Positive cocci were still
Ngdy nhgn bdi: 07/02/2017. ngdy chdp nhgn ddng: 24/02/2017
Nguaiphdn hdi: Trdn Ddc Tiep, Email [email protected] - Benh vien Qudny 103
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N''4/2017 ^ well sensitive to vancomycin, negative bacilli were still sensitive to earapenem group, coiistin and piperaeillin/tazobaetam.
Keywords: Catheter, bacteria, positive gram, negative gram, antibiotic, antibiotic resistance.
I . D a t v a n d e
Nhiem khuan lien quan catheter mach m l u la nguyen nhan dQng thQ ba trong eae nhiem khuan benh vien thudng gap, lam keo dai thdi gian nam vien, t i n g ehi phi dieu trj, t i n g ty le tif vong lien quan den nhiem k h u l n [6]. 0 l t catheter tTnh mach trung t i m la mdt ky t h u l t x l m nhap thudng gap trong thUc hanh y hpe lam sang. Viee lUa chpn khIng sinh (KS) ban d i u theo kinh nghiem hpp ly d l cUu dUde nhieu benh nhan, lieu p h I p KS khdng thfch hdp l l m t i n g ty 1| vi khuan khang thude v l t i n g nguy cd eho ngudl benh. Viee lua chpn KS khdng nhQng dUa tren hUdng dan dieu t n eua eae hiep, hdi ma edn dua v I o c l n nguyen vi khuan eua ttfng khoa, tQng benh vien khae nhau. Vi v l y de tai dupe thUc hien nham Phdn Idp vi khudn vd nghiin cdu mdc dd khdng khdng sinh cua cdc chdng vi khuan phdn lap dugc tgi ddu trong catheter ddt d tfnh mgch dudi ddn.
2. E>6i tUoing va p h u o n g p h a p 2.7. Bdi tdang
Gdm 61 benh nhan (BN) chan thUong sp n l o , dot quy n l o dupc dat catheter tTnh maeh dUdi ddn tai Khoa Dieu trj tfch cUc, Benh vien 198 Ha Ndi tQ t h i n g 11/2014 den t h i n g 7/2015.
Chpn BN: BN tren 18 tudi, chl'n d o l n chan thQdng so n l o , dot quy nao.
Loai BN ra khdi nghien cQu: BN tien sQ mac benh suy g i l m mien djch h o l e dang dieu tri thude Qe ehe mien djch; nam iQu d khoa dQdi 48 gid hoac tien lupng tQ vong trong 48 gid; BN v l gia dinh tQ chdi nghien ciifu.
2.2. Phdtfngphap
Thiet ke nghiin cdu: Nghien cQu tien cQu, md ta.
Xdlysoliiu bang p h l n m^m SPSS 16.0.
Quy trinh nghiin cdu
Theo ddi: Tudi; gidi; chan d o l n benh nen; d\iu tri ehung (ehdng phu nao: Thd oxy, dau eao 30 dp, dat npi khi q u I n , t h d may...; kiem s o l t huyet ap;
t i n g cQdng dinh dudng nao; dieu trj p h l u thuat;
dieu trj c l e trieu chQng...) cua benh n h i n . Dat catheter tTnh mach dUdi ddn loai 2 nong theo phUdng phap Seldinger.
Ky t h u l t lay dau trong catheter:
Thdi diem lay benh pham: Khi rut catheter theo chi djnh ciia b i c s y .
PhUdng tien sQ dung: Khay, x I n g , keo vd khuan, gang tay vd khuan; dung djch sat khuan (edn 70 dp, betadin). Ong nghiem vd khuan.
PhQdng p h I p ti^n hanh: S i t edn 70 dd sau do bang Betadine tai c h i n catheter v l xung quanh. Trli x I n g vd khuan va dung keo eat chi cd djnh catheter.
G i p het c l e v l y m l u b I m xung quanh catheter bang kep khdng cd mdc. S i t khuan bang Betadine lai mdt l l n nQa. Rut nhanh catheter ra khdi Idng mach, ngudi phu e l m dng nghiem v l md nap dng, ngudi riit dat dau catheter vao trong dng nghiem, dung keo vd khuan eat doan dau catheter khoing 5cm eho vao trong dng nghiem vd khuan va day n i p lai gin len khoa xet nghiem vi sinh de nudi ely djnh dang vi khuan va l l m khang sinh do.
Cl'y dau trong catheter (khi rut catheter): Mdi trudng thach mau, thach soeola, thaeh Me. Conkey de t i l am 3 - 5% CO2/ 33 - 3 7 ^ , 24 - 48 gid.
Cleh eay: Ria d phan tQ thU 1. Ria hai lan d phan tQ thQ 1 rdi sau dd ria lui va tdi de eay sang phan tU thQ 2. Rla hai lan d phan tQ thU 2 rdi sau dd ria lui va tdi de cay sang phan tU thQ 3. Ria hai lan d phan tU thQ 3 rdi sau d d ria lui va tdi de cay sang phan tQthQ 4. Cay d i m mdt vai lan tren thaeh m l u .
Bpe ket qua: 0 (khdng thay vi khuan); < 1 (hiem);
I - 4 (rat ft); 5 - 9 (ft); 10-50 (trung blnh); > 50 (nhieu).
Xae djnh can nguyen vi khuan va l l m khang sinh d d :
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Nguyen ly: Theo ddi lien tue sU p h l t trien cOa vi sinh v l t trong c l e gieng cOa t h ^ (card).
Phuong tien: Binh dang vi khuan bang may Siemen Micro Sean Walk way40.
Dung phUdng p h I p do mau d ^ nhan b\ix ele tinh chat sinh vat h o i hpc cOa vi sinh vat thdng qua SLf thay ddi m l u eiia cac gleng mdi trudng ed san trong the.
PhUdng phap lam khIng sinh do: DCing phuong phap do MIC (ndng dp Qe che tdi thieu), do dp due de theo ddi sU phat trien ciia vi sinh v l t (VSV) trong cac gieng ciia card. B l n h ket qua theo c l e mQc dd:
Nhay (Sensitive - S); trung gian (Intermadiate - I);
khang (Resistance - R).
Ky thuat k h I n g sinh do: Tien h l n h theo phuong p h I p Kirby-bauer c l i tien da dugc ehuan hda tai Vien Vi trung Qude gia Stockholm, Thuy Bien. B l n h g i l ket q u i theo bang chuan.
Chi tiiu nghiin cdu
Kix q u i p h l n lap vi khuan tai dau trong catheter.
Thanh phan cac loai vi khul'n phan lap dupe tai dau trong catheter.
Ket q u i ve mQc dp nhay e l m vdi khang sinh cCia c l e vi khuan p h l n lap dQpe.
3. Ket qua
3.7. Ket qu^ phan lap vi khuan tai dau trong catheter
B i n g 1 . So mau benh pham lay dUOc va ty le moc vi khuan Nhom
Nhom CO ket qua cay duong tmh Nhom CO ket qu3 cay am tinh
Tong
So mau benh pham 15 46 61
T i l c % 24,6 75,4 100 Nhdn xit Ty le vi khuan mpc d cae mau benh pham tai dau trong catheter tTnh mach trung t i m d ddi tupng nghien cUu la 24,6%.
3.2. Thanh phan cac loai vl khuan phan lap ddoctaidau trong catheter
BIng 2. Thanh phan cac loai vi khuan phan lap dUdc tai dau trong catheter Ten vi khuan
Cau khuan gram duong Staphylococus aureus Staphylococus epidermidis True khuan gram am
Acinetobacter baumanii Klebsiella pneumoniae Pseudomonas aeruginosa Enterobacter
long
So chung
2 4
3 3 2 1 15
T y l # %
13,3 26,7
0,2 0,2 13,3 6,7 100
Tong
40,0
60,0
100 NhgnxetTTong 15 ehiing vi khuan p h l n lap dQpe, ed 6 ehung (40%) eau khuan gram dUdng, true khuan gram am gap 9 ehiing (60%).
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3.3. Ket qui ve mdc dp nhay cim vdi khang sinh cua cac vi khuan phin lap dddc 3.3.1. Staphylococus aureus
B i n g 3. D o nhay cam k h a n g sinh cua Staphylococus aureus
Khang sinh Ceftriaxone Ertapenem Pipe/Tazo Ampi/Sul Penicilin Imipenem Tobramycine Vancomycine Levofloxacine Meropenem
T6ng so chiing 2 2 2 2 2 2 2 2 2 2
So chung nhay 0 0 0 0 0 1 0 2 0 1
56 chQng t r u n g gian 0 0 1 0 0 0 0 0 0 0
So chCing Ithang 2 2 1 2 2 1 2 0 2 1 Nhdn xet S.aureus khang hau het eae k h I n g sinh nhUng nhay vdi vancomycin.
3.3.2. Staphylococus epidermidis
B i n g 4 . D o nhay e l m khang sinh cua Staphylococus epidermidis
Khang sinh Ceftriaxone Penicillin Ertapenem PipeH'azo Ciprofloxacin Amikacin Imipeneme Gentamycin Vancomycine Levofloxacine iVleropenem
TongsochDng 4 4 4 4 4 4 4 4 4 4 4
So ch Cing nhay 0 0 3 3 0 2 3 0 4 3 3
So chijng t r u n g gian 1 0 0 1 1 0 0 1 0 0 0
So chiing Ithang 3 4 1 0 3 2 1 3 0 1 1 Nhdn xet S.epldemidis c d t y le khang cao vdi eac k h I n g sinh thudng, nhdm eacbapenem cdn nhay e l m (75%), vancomycin (100%).
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3.3.3. Acinetobacter baumannii
Bdng 5. D d nhdy cSm k h a n g sinh cua Acinetobacter baumanii
Khang sinh Ceftazidin Amikacin Pipe/Tazo Ciprofloxacin Cefipime Imipeneme Coiistin Vancomycine Levofloxacine Meropenem
Tong s£i Chiang 3 3 3 3 3 3 3 3 3 3
So chCing nhay 0 0 2 0 0 0 3 0 0 2
So chCing t r u n g gian 0 0 0 0 0 1 0 0 0 1
So chCing ithang 3 3 1 3 3 2 0 3 3 0 Nhdn xet A.baumanii khang hau het e l e k h I n g sinh thUdng sQ dung, ehi edn pipeeillin/tazobactam, nhay cam vdi coiistin (100%) va meropenem (66,7%).
3.3.4. Klebsiella pneumoniae
Bang 6. D o nhay cam k h a n g sinh cDa Klebsiella pneumoniae
Khang sinh Ceftazidin Amikacin Pipe/Tazo Cef/Sulbactam Cefipime imipeneme Coiistin Ciprofloxacine Levofloxacine iVleropenem
Tong so chCing 3 3 3 3 3 3 3 3 3 3
So chCing nhay 0 1 1 0 0 1 3 0 0 2
So chCing trung gian 0 0 0 0 0 1 0 0 1 1
So chung Ichang 3 2 2 3 3 1 0 3 2 0 Nhgn xet: Kpneumonio khang hSu het cac nhom khang sinh, tazocin va nhom carbapenem con co tac dung coiistin con nhay cSm (100%).
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3.3.5. Pseudomonas aeruginosa
Bang 7. D o nhay cam k h a n g sinh ciia Pseudomonasaeruginosa Khang sinh
Ceftriaxone Ertapenem Pipe/Tazo Cef +Sulbactam Cefipime Imipeneme Coiistin Levofloxacine IVleropenem Amikacin
Tong so chung 2 2 2 2 2 2 2 2 2 2
So chiing nhay 0 0 1 0 0 0 2 0 1 0
S6 chQng t r u n g gian 0 0 0 0 0 0 0 0 0 0
So chCing Ithang 2 2 1 2 2 2 0 2 1 2 Nhdn xit Pseudomonas aeruginosa khang hau het t i t e l k h I n g sinh. Chi edn nhay cam vdi piperaeillin/tazobaetam, coiistin va meropenem, coiistin cdn nhay d m 100%.
3.3.6. Enterobacter
B i n g 8. D o nhay cdm khang sinh cua Enterobacter Khang sinh
Ceftriaxone Ertapenem Pipe/Tazo Cef +Sulbactam Cefipime Imipeneme Coiistin Vancomycine Levofloxacine IVleropenem
Tong s£i Chung So chiing nhay 0 0 1 0 0 0 1 0 1 1
So chung t r u n g gian 0 1 0 0 1 0 0 0 0 0
So chiing Ithang 1 0 0 1 0 1 0 1 0 0 Nhdn xet Enterobacter k h I n g h l u het cae k h I n g sinh, edn nhay e l m vdi meropenem, coiistin, levofloxacin va piperacllin - tazobactam.
4 . Ban luan
4.7. Ve can nguyen vi khui'n gay nhiem khuan tai dau trong catheter
Ket q u i d BIng 1, eay 61 dau catheter cay khuan ed 15 mau (24,6%) benh pham duong tfnh. Ty \& n l y eao hPn bao eao eiia B o l n Minh Tuan [2] khi nghien
eUu 200 BN dat catheter tinh maeh trung t i m cd 33 mau (16,1%) benh pham dUOng tfnh. T^y" le dUdng tfnh ciia nghien cUu do ddi tUdng nghien cQu gdm c l e benh n h i n CTSN va TBMMN, nhap vi^n trong tinh trang nang, mac c l e benh man tfnh, dQpe thdng khf nhan tao va dUpc phau thuat dieu trj.
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4.2. Ve die diem vl khuan hgc gay nhiem khuSn catheter
d BIng 2 trUe khuan gram I m chiem 60%
{/^.baumanni v l Kpneumonio chiem 20%), eau khuan gram dUong chlem 40% [Staphylococuc epidermidis chiem ty le cao n h l t 26,7%; S.aureus chiem ty le 13,3%), khdng thay ed nhiem nam (cd the so lupng nghien cQu ehUa dQ Idn). T;^ le nhiem khuan catheter trong nghien cQu phu hpp vdi b i o e l o eua B o l n Minh Tuan [2] (nhiem khuan catheter do S.aureus 21,2%, S.epidermidis I I 27,3%, A.baumanni la 18,2%, Kpneumonio la 12,1%), Vu Blnh Hung [3] nghien cQu tinh hlnh nhiem khuan lien quan den catheter tai Benh vien Bach Mai (nhiem k h u l n gram am la 61,6%
trong dd do A.baumanii 28,5%; Kpneumonio ehiem 9,5%).
4.3. Sd khang khang sinh cua cac chiing vi khuan phan lip ddcfc tai dau trong catheter
4.3.1. Staphylococus aureus
Ket qua d BIng 3 cho thay S.aureus khang hau het vdi khIng sinh thude nhdm betalaetam, levofloxacin, piperacllin -i- tazobactam. Khang sinh nhdm carbapenem chi cd imipenem v l meropenem la cdn nhay e l m vdi t;y' le 1/2 sd ehiing p h l n lap. Tu cau khuan ed kha nang g l y benh vdi t i le rat eao, khIng khang sinh rat manh. Trong sd c l e chCing t u cau, S.aureus hay gay nhiem khuan catheter tTnh maeh trung tam, ed dae tfnh sinh beta-laetamase (80 - 90%), vl the dieu trj khang sinh (KS) betalaetam thdng thudng khdng hieu qua. Ket q u i cOa nghien cQu cung phu hpp vdi Boan Minh Tuan [2] v l Vu Dinh Hung [3]. Trong nghien cQu, chua thay S.oureus khIng vancomycin. Trgn l l m sang, vancomycin I I khIng sinh lua chpn hang dau khi nhiem khuan S.atJfeus ma ehUa ed ket q u i k h I n g sinh d d .
4.3.2. Staphylococus epidermidis
Cs Bang 4, S.epidermidis k h I n g h o l n t o l n vdi penicillin, 2/4 sd ehiing p h l n lap khang amikacin. KS carbapenem (levofloxacine, piperacilin -I- tazobaetam) I11/4 sd chiing. D i e biet t r o n g 4 e h u n g S.epidermidis p h l n lap dupc, khdng cd ehung nao khIng vdi vancomycin. T^ le khang k h I n g sinh eiia
S.epidermidis trong nghien cQu cOa ehung tdi cao hdn B o l n Minh Tuan [2]. Do dd, p h l i ed chien lupc sQ dung vancomycin thfch hpp, t r i n h de x l y ra tinh trang khang vancomycin eiia cle chiing tu eau. Cac trQdng hpp nhiem t u c l u , ehua cd k h I n g sinh do thi vancomycin van I I lUa chpn hang d i u .
4.3.3. Acinetobacter baumannii
Trong nghien euli, ehung tdi p h l n lap dUpc 3 ehiing A.baumannH. CIc chiing n l y khIng vdi hau het ele KS nhU: Ceftazidin, levofloxacine, amikacin, cefipime (Bang 5), 2/3 sd ehiing khIng vdi imipenem, ehUa cd vi khul'n k h I n g meropenem v l coiistin (tat ea 3 chQng deu nhay e l m vdi coiistin). J^
le k h I n g KS eua A.baumannii trong nghien cQu phii hpp vdi ket q u i nghien cQu cQa B o l n Minh Tuan [2], Vu Binh HUng [3] tai Benh vien Bach Mai Abaumannii k h I n g hau het eac khang sinh, nhdm carbapenem eung bi khang h o l n t o l n .
Tai Viet Nam, theo thdng ke chfnh thQe cita Bp Y te n I m 2004, tinh hinh khang KS cQa A.baumanii ddi vdi ceftazidin va ciprofloxacin lan iQpt I I 64% va 55%. Tai Bi khi nghien eUu ve khang KS tai ele khoa dieu trj tieh cue thay ed tdi 80% eae ehiing Acinetobacter khIng thude [1]. Tai My, ngay tU nhQng nam 1988 da xuat hien ele chQng Acinetobacter khang vdi nhieu loai KS, nhat I I KS thupc nhdm carbapenem da tang l^n nhanh ehdng [4]. Nhu v l y , xu hudng k h I n g KS eiia A.baumannii n g l y cang tang, cle KS thude nhdm carbapenem ngay cang it nhay e l m .
4.3.4. Klebsiella pneumoniae vd cdc chung gram dm khac
Ket q u i d BIng 6, 7 va 8 cho thay 2/3 sd chQng Kpneumonio di khIng eao vdi amikacin, tazocin, levofloxacin, nhUng cdn nhay cam t d t vdi imipeneme. ChUa thay chung vi khul'n n l o khang vdi meropenem va dac biet la coiistin. Cle KS thude nhdm betalaetam ed X>j le khIng thude 100%, ke c l khi phdi hpp eung P-laetamase. Nguygn nhan ciia viec K.pneumonia khang vdi KS thude nhdm quinolon va p-laetam cao nhU tren ed k h i nang do hai KS nay thUdng xuyen dupe sQ dung de dU phdng nhiem khuan tai Benh vign 198, dieu dd dan tdi tinh
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trang khang KS cua Kpneumonio vdi cae KS nay tai Benh vien 198. Ty Ig k h I n g thude trong nghien cQu cung phii hpp vdi b i o eao nghien cQu cQa B o l n Minh Tuan [2] tai Benh vien 103 va Vti Binh HQng [3]
khi nghien cQu ty le khang KS tai Benh vien Bach Mai. Trong q u i trinh nghien cQu, ngoai ele true khuan gram am nhU Abaumanii v l Kpneumonio, ehung tdi gap 2 ehiing P.aeruginosa v l 1 chung Enterobacter. C l 2 loai vi khuan gram I m n l y deu cd su de khang khang sinh r l t cao, k h I n g hau het vdi ele khIng sinh, d i e biet la S.aeruginosa ehi cdn nhay e l m vdi coiistin, tazocin va meropenem [4]. Tuy nhien do sd ddi tUpng tham gia nghien cQu cdn ehua cao nen ket q u i eiia nghien cQu ehi mang y nghla tham khIo.
5. Ket ludn
Qua nghien cQu cl'y khuan dau trong catheter tTnh maeh dUdi ddn eua 61 benh nhan dieu t n tai Khoa Bieu tn tfch cUc, Benh vien 198 H I Ndi tQ t h i n g 11/2014 den t h i n g 7/2015, chung tdi nhan thay:
C l n nguyen g l y ra nhiem khuan dau trong catheter ehii yeu la cae true khuan gram am (60%), trong dd A.baumanii 20%; K.pneumonia 20%;
S.aeruginosa 13,3% v l Enterobacter 6,7%; cac eau khuan gram dUOng (40%) trong dd S.epidermidis 26,7% va S.aureus chiem X^ le thap hon 13,3%.
Khdng thay nhiem nam.
Cac chOng vi khul'n phan lap dQpe ed ty le de khang cao vdi mpt sd khang sinh:
Cau khuan gram dUong k h I n g hau het vdi ele k h I n g sinh thdng dung nhQ: Ampielllin/sulbaaam, penieillin, tobramycine, ceftriaxone. Chua thay ehiing staphylococus n l o khang vdi vancomycin.
True khuan gram am khang k h I n g sinh rat cao, ehi edn nhay e l m vdi nhdm carbapenem, coiistin v l piperaeillin/tazobaetam.
Tai lieu t h a m k h I o
1. Elliontt TSJ, Tebbs SE, Moss HA et al (2000) A novel serological tes for the diagnosis of central venous catheter - associated sepsis. J Hosp infection 40:
262-266.
2. Doan Minh Tuan (2008) Nghiin cdu cdn nguyin vi khudn, mot sd yiu to lien quan din nhiem khuan catheter tai hai vi tri tinh mgch cdnh trong vd tinh mgch dudi don. Luan van thac sy y hpe. Hoc vien Quan y. Ha Ndi.
3. Vu Dinh HUng (2012) Ddnh gid tinh hinh nhiem khudn binh viin liin quan den catheter ttnh mgch trung tdm tgi Khoa Hoi sdc tich cUc Binh viin Bgch Mai. Luan van thac sy y hpc. Trudng Bai hpc Y Ha Ndi.
4. Blot S, Vandewoude K (2000) Nosocomial bacteremia caused by antibiotic - resistant gram- negative bacteria in critical ill patients clinical outcome and length os hospitalization. Clin infect Dis 34(12): 1600-1606.
5. Paterson DL (2004) Collateral damage from cephalosporin and quinolone antibiotic therapy.
Clinical infectious diseases 38(4): 341 -345.
6. Le Bao Huy (2013) Khdo sdt tinh hinh nhiim khuan huyet liin quan catheter tgi Khoa Hdi sdc tich cue Chong dgc Binh viin Thong Nhdt Thdnh phdHd Chi Minh. Y hpe thanh phd Hd Chi Minh, tap 17, phu b i n cCiasd1,tr. 262-267.
