JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12 - N''3/20)7
Tinh trang de khang khang sinh in vitro cua vi khuSn tren benh nhan benh da bong niro^c tu* mien tai Benh vien Da ligu thanh ph6 Ho Chi Minh
In vitro antibiotic resistance of bacteria in patients with bullous skin diseases at Ho Chi Minh City Hospital of Dermato-Venereology
Nguyen Thi Thtiy Nga, Trudng Dgi hoc YDugc thanh pho Ho CMMinh Nguyen T^t ThSng, Van Thi Trung
Muc tieu: Nham xac djnh tinh trang bdi nhiem va khdng khdng sinh in vitro d b i n h nhan benh da bong nude t u mien. Doi tugng vd phuang phdp: Bao cao hang loat ca tren benh nhan benh da bdng nUdc tu mien cd sang thuong da nghi ngd bdi nhiem dieu trj ndi tru tai Khoa Lam sang Binh vien Da lieu thanh pho Ho ChiMinhtU 10/2014 den 5/2015./Cettjud: Chung tdi khdo sat 37 trUdng hap benh bdng nude t i ; mien. C6 28 benh nhdn (75,7%) ed ket qud cay vi khuan dUOng tfnh. Trong sd cdc benh nhdn nay, 60,7% la do Staphylococcus aureus khdng methicillin (MRSA), 28,6% do Pseudomonas aeruginosa: 21,4% do Staphylococcus aureus nhay methicillin (MSSA), 3,6% do Staphylococcus epidermidis. 3,6% do Escherichia cdi ESBL (-), 3,6% do Escherichia coll ESBL (+). Khang sinh dd cua vi trung phan lap dUOC cho thay MSSA de khang cao vdi penicilline, cefuroxime, cefoxitin, clindamycin, erythromycin, ciprofloxacin, gentamycin vd Pseudomonas aeruginosa di khang cao vdi tetracycline, co-trimoxazol. Ket ludn: Nhiem khuan da trin benh nhan benh bdng nUdc t u mien la phd bien, dac biet la nhiem Staphylococcus aureus va Pseudomonas aeruginosa. Ddy la cdc loai vi khuan de khdng vdi khdng sinh thdng dung nhu penicilline, cefuroxime, cefoxitin, clindamycin, erythromycin, ciprofloxacin, gentamycin, tetracycline, co-trimoxazol.
TUkhda: De khang khdng sinh, benh da bdng nude t u mien.
Summary
Objective: This study was to determine the status of infections and antibiotic resistance in vitro in patients with autoimmune bullous skin diseases on inpatient. Subject and method: A ease series descriptive study among patients with autoimmune bullous skin lesions suspected superinfection on inpatient treatment at the Ho Chi Minh City Hospital of Dermato-Venereology from October 2014 to May 2015. Result. We observed 37 patients with immuno-bullous diseases. There were 28 cases (75.7%) with positive bacteriological culture. Among these 28 patients, methicillin-resistant Staphylococcus aureus (MRSA) were 60.7%; P. aeruginosa were 28.6%; methicillin-sensitive Staphylococcus aureus (MSSA) were 21.4%; Staphylococcus epidermidis were 3,6%; Escherichia coli ESBL (-) were 3.6%; Escherichia coli ESBL (+) were 3.6%. The antimicrobial susceptibility of isolated bacteria indicated that MSSA was highly resistant to penicillin, gentamycine, clindamycin, chloramphenicol, erythromycin, MRSA was highly resistant to penicillin, cefuroxime, cefoxitin, clindamycin, erythromycin, ciprofloxacin, gentamiein and
Ngdy nhdn bat: 10/11/2016, ngdy chdp nhgn ddng- 16/11/2016
Nguaiphdn hoi: Vdn The Trung. Email [email protected] - Trudng Dqi hoc YDugc thdnhphoHd Chi Minh
TAPCHfYDUqCLAMSANG 108 Tap 12-So 3/2017
Pseudomonasaeruginosa was highly resistant to tetracycline, co - trimoxazol. Conclusion: Bacterial skin infections were common in patients with immuno-bullous diseases, particularly infections with Staphylococcus aureus and Pseudomonas aeruginosa. These bacteria were highly resistant to various antibiotic agents such as penicillin, cefuroxime, cefoxitin, clindamycin, erythromycin, ciprofloxacin, gentamiein and Pseudomonas aeruginosa was highly resistant to tetracycline, co-trimoxazol.
Keywords: Antibiotic resistance, autoimmune bullous skin diseases.
1. Dat Vein de
B i n h da bdng nude tU mien la mdt trong nhdng mat benh thUdng gap d benh nhan dieu trj ndi tru tai Benh vien Da li^u thanh phd Hd Chi Minh (TPHCM). Cdc bdng nude ed the v d va t h u d n g dUa den bdi nhiem. Nghien cdu nay dUpc tien hanh nham cung cap eac d d lieu khoa hpc ve mdi tUOng quan gida cdc ddc diem lam sang vdi tinh trang bdng nUdc bdi nhiem, dinh danh vi khuan bdi nhiem thUdng gap va tfnh khang khdng sinh cua vi khuan nay. Ket qud nghien cdu cung gdp phan ho trd bdc sT Idm sang trong v i i c cho khang sinh dung chi djnh, nhanh chdng, phu hdp, nham dat hieu qua trong dieu tri cung n h u ban che tinh trang de khang khang sinh. Mue tieu n g h i i n cdu la Xdc djnh tinh trgng bdi nhiem vd khdng khdng sinh in vitro d binh nhdn benh da bong nUdc tU mien dieu tri ndi tru tgi Binh vien Da lieu TPHCM tdthdng 10/2014 den thdng 05/2015.
2. Ddi tdofng va phUdng p h i p Thietkenghien cdu: Bao eao hang loat ca.
Chon mau: Tat cd b i n h nhan benh da bdng nUde tu mien ed sang thuong da nghi ngd bdi nhiem nhap viin trong vdng 48 gid tai Khoa Lam sang Binh vien '• DalieuTPHCMtd10/2014den5/2015.
Chan dodn binh bdng nUdc tU mien: DUa vao kham lam sang va giai phau benh.
Mau benh pham de cay vi khuan dupe lay t d bdng mu, trot da tiet dich vdng. Lau sach da lanh xung quanh bang cdn 70°. Mau benh pham dUdc thu thdp t d t a m p o n vd trdng, cho ngay vdo dng n g h i i m vd cay tai khoa xet nghiem. Sd dung kT thuat khuech tan khang sinh trong thaeh. Moi benh ' pham duac cay len 2 mdi t r u d n g : BA (Blood Agar) vd EMB (Eosin methylene blue). Mdi t r u d n g BA de phdn lap eau khuan gram d u a n g , mdi trudng EMB
diJng 66 phdn lap true khuan gram am. Sau khi cay bang ky thuat vach 3 chieu, BA duac u trong blnh nen d nhiet dp 37^0 trong 24 gid, cdn EMB thi Ci d nhiet do 37°C trong 24 gid. De t u am cho vi khuan mpc va do dudng kinh vdng dc che vi khuan xung quanh khoanh giay khang sinh, dUa vao d d xac djnh mdc dp nhay cdm eua vi khuan duoc t h d vdi khdng sinh d d .
3.KetquS
Ddc diim djch te, idm sdng cOa mau nghiin cdu Trong 37 benh nhan dUOc khao sdt, ed 25 n d (67,6%) va 12 nam (32,4%). Ve dp tudi, ed 8 benh nhdn (21,6%) dudi 30 tudi, 22 benh nhan (59,5%) t d 31 - 59 tuoi va 7 benh nhan (18,9%) tU60 tudi trd len.
Ve benh da tren ddi tupng nghien cdu, chu yeu la benh pemphigus thdng thudng (54,1%), benh bdng nude dang pemphigus (24,3%), ke den Id b i n h da IgA theo dudng (10,8%), pemphigus la (8,1%), pemphigus sui (2,7%).
Logi vi khuan vd tinh trgng khdng khdng sinh in vitro
Trong 37 b i n h nhan lam xet nghiem c^y vi trijng tai sang thuong da nghi ngd bdi nhi^m, cd den 28 trUdng hop cd ket qud cay duang tinh (75,7%).
Bdng 1 . Tac nhan phan lap vi trdng tren sang thucmg da (n = 28) Phan lap vi trung Staphylococcus aureus nhay methicillin Staphylococcus aureus khang methicillin Staphylococcus epidermidis Pseudomonas aeruginosa Escherichia coll E5BH-) Escherichia coli ESBL (+)
T i n so (n) 6
17 1 8 1 1
T y l # % 21,4
60,7 3,6 28,6 3,6 3,6
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY VoLl2-N=3/aoi7
Trong sd 28 benh nhdn cd ket qud cay vi triing trung (khdng ed trudng hap nhiem tU 3 loai vi trung duong tfnh thi cd den 17 trUdng hpp (60,7%) Id do t r d len) g o m : 4 trudng hpp nhiem S.aureus khang Staphylococcus aureus khang methicillin, 8 trudng methicillin vd Pseudomonas aeruginosa; 1 trudng hap (28,6%) do Pseudomonas aeruginosa, 6 trudng hap nhiem Staphylococcus aureus nhay methicillin hpp (21,4%) do Staphylococcus aureus nhay va Pseudomonas aeruginosa; 1 trudng hpp nhiem methicillin. Trong dd, 6 ngUdi bj nhiem 2 loai vi Pseudomonas aeruginosa va Escherichia coli esb\(+].
Bdng 2 . Tinh trang khang khang Khang sinh
Penicilline Cefuroxime Cefoxitin Vancomycin Clindamycin Chloramphenicol Erythromycine Tetracycline Ciprofloxacine Gentamycine Co-trimoxazol Pristinamycin Rifampicin Linezolide
sinhcijaS.
Khang n 5 0 0 0 4 4 4 0 3 5 0 0 1 0
83,3
%
0 0 0 66,7 66,7 66,7 0 50 83,3
0 0 16,7
0
aureus nhay methiciliin Nhay n 1 6 6 6 0 2 0 2 3 1 6 6 5 6
16,7
%
100 100 100 0 33,3
0 33,3
50 16,7 100 100 83,3 100
(MSSfl)(n = i) Trung gian n 0 0 0 0 2 0 2 4 0 0 0 0 0 0
%
00 0 0 33.3
0 33,3 66,7 0 0 0 0 0 0 MSSA de khdng cao vdi penicilline, gentamycine, clindamycin, chloramphenicol, erythromycin.
BSng 3. Tinh trang khang khang sinh ci^a S. aureus khang methicillin (MRSA) (n = 17) Khang sinh
Penicilline Cefuroxime Cefoxitin Vancomycin Clindamycin Chloramphenicol Erythromycine Tetracycline Ciprofloxacine Gentamycine Co-trimoxazol Pristinamycin Rifampicin Linezolide
Khing n 17 17 17 0 17 5 17 3 17 17 1 0 1 0
100
%
100 100 0 100 29,4 100 17,6 100 100 5,9 0 5,9
0
Nhay n 0 0 0 17 0 12 0 8 0 0 16 17 16 17
%
00 0 100
0 70,6
0 47,1
0 0 94,1 100 941 100
Trung gian n 0 0 0 0 0 0 0 6 0 0 0 0 0 0
%
00 0 0 0 0 0 35,3
0 0 0 0 0 0 MRSA de khang eao vdi penicilline, cefuroxime, cefoxitin, clindamycin, erythromycin, ciprofloxadn, gentamycin.
TAP CHl Y DLtgc LAM SANG 108 Tap 12-So 3/2017
Being 4 . T i n h t r a n g k h a n g k h a n g sinh cua P. aeruginosa (n = 8)
Khang sinh TIcarcillin/clavulanIc acid Ceftazidime Cefotaxim Ceftriaxone Cefepime Tetracycline Ciprofloxacine Gentamycine Tobramycine Amikacine Netilmicine Co-trimoxazol Meropenem PIperacillin/tazobactam
Khang n 0 0 0 2 0 8 0 0 0 0 0 8 0 0
%
0 0 0 25,0
0 100
0 0 0 0 0 100
0 0
Nhay n 8 8 0 1 8 0 8 8 8 8 8 0 8 8
%
100 100 0 12,5 100 0 100 100 100 100 100 0 100 100
Trung gian n 0 0 8 5 0 0 0 0 0 0 0 0 0 0
%
0 0 100 62,5 0 0 0 0 0 0 0 0 0 0 Pseudomonas aeruginosa de khang cao vdi tetracycline, co-trimoxazol.
4. Ban ludn
Dac diim dich te, lam sdng cda mau nghien cdu Cd tdi 78,4% d trong dp tudi t r i n 31 tuoi, tuang t u vdi n g h i i n edu cda Trdn Ngoc Anh [9] la 75%, trong khi dd tre em chi chiem 8%. Dieu nay phu hop vi trong mau nghien edu cua chCing tdi, benh pemphigus thdng thudng va b i n h bdng nUde dang pemphigus chiem da sd. Va hai benh nay ehCi yeu gap d b i n h nhan t r i n 31 tuoi [2].
V I gidi, t y l i nd/nam la 2,08/1. PhiJ hpp vdi ket qua n g h i i n cdu eCia Tran Ngpc Anh nd/nam Id 1,67/1 [9], Tim So Thea nO/nam la 2,08/1 [8]. Tuy nhien, theo y vdn va cae nghien cdu ngoai nUdc, ghi nhdn benh gap d hai gidi vdi t y l i tUdng dUdng nhau, nhu nghien edu cua Stanley [7].
Trong 37 ca b i n h cCia ehung tdi thi cd den ban 50% la pemphigus thdng thudng, ke den la bdng nudc dang pemphigus c h i l m 24,3%, benh da IgA dudng chiem 10,8%, pemphigus la chiem 8 , 1 % , pemphigus siji chiem 2,7%. Phdn bd x^ le b i n h da bdng nude t u mien trong nghien cdu cOa ehung tdi Id phu hdp vdi y van [7]. SU phu hop nay cd the gidi
thfch la do Binh vien Da l i i u TPHCM la b i n h vien t u y i n dau ve da lieu d khu v\sc phfa Nam, va benh bdng nudc t u mien la benh ly da nang, nen hau het benh nhdn mac benh bdng nude tU mien se den khdm va dieu tri tai day.
Cd 35 benh nhdn than phien v l cdm giac da, thi cdm giac dau chiem ty le cao nhat (85,7%), tiep theo la mui hdi (54,3%), bdng rat (31,4%), ngda (20%), sdng (14,3%). Do chiSng tdi chpn mdu la nhOng sang thUdng bdng nude nghi ngd bdi nhiem dua tren t i i u chf cua CDC 2006 [5] gdm ed bdng mil, dau, sdng, do tai sang thuong da; nen t y le trieu chdng dau chiem Uu the la phu hpp.
Tat ed benh nhdn deu ed dp nang b i n h t d dp 2 t r d l i n , trong dd dp 2 (56,8%) chiem ty' le eao ban dp 3 (43,2%). Vi chung tdi chpn mau la nhdng benh nhdn dieu trj ndi tru tai khoa lam sang cd sang t h u a n g bdng nudc nghi ngd bdi nhiem n i n mau nghien cdu chi bao gom nhOng benh nhan cd dp nang tU trung binh t r d len.
Logi vi khuan vd tinh trgng khdng khdng sinh in vitro trin sang thuang bdng nudc tumien bdi nhiem
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.l2-N'3/2017
Nghien cdu eCia chung tdi ghi nhan t y le sang thuong bdng nUdc t u mien bj bdi nhiem chiem 75,7%, ty le nay la khd cao mac du b i n h nhan ehung tdi chi chpn cac benh nhdn nhap vien trong 48 gid dau. Dieu nay cho thay su nhiem khuan khdng han la do t d mdi trudng benh vien ma do v l t thuang h d da tren ca the b i n h nhan benh t u mien gidm sdc de khang va sd dung eac thuoc Uc c h i mien dich. Ty l i nhiem khuan da trong nghien cdu eua chiing tdi eung tuong ddi cao so vdi cac nghien cdu trong va ngoai nUdc khdc. Nghien cdu cua tdc gid Nguyen Thj Dieu My ghi nhan t:J' l i nhiem khuan b i n h v i i n tren cac sang thuang da hd chiem 53,9% [5]. Ty le nhiem khu^n b i n h v i i n trong ede nghien cdu ngodi nUdc nhu nghien cdu cua Sarginson (Anh) [6] vd Abramczyk (Brazil) [1] l l n luat Id 41,9% va 46,1%.
Dieu nay cd the do mau nghien cdu eua chUng tdi tap trung vao nhiem vi khuan cdng ddng vd benh nhan trong nghien edu cd sang thuong da h d t d mde dp trung binh t r d len. Trong dieu kien mdi trUdng d nhiem nhu V i i t Nam, nhUng benh nhan ndy de bj cdc loai vi khuan xam nhdp vd gay benh.
Trong khi dd, cae n g h i i n cdu khac tap trung vao nhiem khuan benh vien vd lay mau benh pham vi sinh d nhieu vj tri khde nhau (da, ti^t nieu, hd hap).
Ket qud n g h i i n cdu cho thay ty le khdng thuoc cCia tu cau vang nhay methicillin (MSSA): Khang cao nhat vdi penicilline va gentamycin (83,3%), clindamycin, chloramphenicol, erythromycin vdi cung t j ' l i 66,7%. Rifampicin khdng vdi ty le thap 16,7%. !•)/ le khdng thude cua tu cau vdng khang methicillin (MRSA): Khdng 100% vdi penicilline, gentamycin, clindamycin, cefuroxime, cefoxitin, erythromycine, ciprofloxacin, tiep theo la chloramphenicol, tetracycline vdi t y le Ian lUpt la 29,4% v a i 7,6%.
Theo ket qud nghien cdu cho thay ty le de khang gida MRSA va MSSA vdi ede khang sinh thuoc nhdm (5-lactam, ngoai trU ty le de khang penicillin ciia ca hai ehijng deu rdt eao (100% va 83,3%), eac khdng sinh cdn lai thi MRSA cd ty le de khang cao hdn MSSA. Vdi mdt sd khang sinh tieu bieu khdng phdi p-lactam cung cho thay MRSA cd ty le khdng cao hon MSSA nhU; Clindamycin (100% va 66,7%),
erythromycine (100% va 66,7%), ciprofloxacine (100% vd 50%), gentamycine (100% so vdi 83,3%),
Tmh hinh de khdng khdng sinh cua P. aeruginosa.
Trong nghien edu ndy, Pseudomonasaeruginosa d l khdng cao vdi tetracycline (100%), co-trimoxazol (100%). T;^ le nhay cao ban so vdi nghiin cuti cCia Nguyen Thj Dieu My [5] va nghien cUu cCia Nguyen Thanh Bdo [4]. Tac gid Dieu My ghi nhdn dp nhay cua Pseudomonas aeruginosa vdi ticarcillin/clavulanic acid (85,7%), ciprofloxacine (78,6%), gentamycine (21,4%), amikacine (64,2%), netilmicine (78,6%), meropenem (85,7%). Tdc gid Nguyen Thanh Bao ghi nhdn t j ' l i nhay vdi meropenem (78,2%).
Dp nhay cam khang sinh trong nghien edu cua chung tdi eao hdn so vdi cdc nghien cUu trong rvsdc.
SU khac biet ve do nhay cdm khdng sinh cOa Pseudomonas aeruginosa cd the la do nghiin ciSu cua chung tdi ghi nhdn tinh trang nhiem khuan cdng ddng, trong khi cac nghien cdu khac ddnh gia nhiem khuan benh v i i n . TrUdc day, vi khuan nay duoc xem la nguyen nhan thudng gap cua nhiem khuan benh vien tren benh nhan ndi tru lau nay,va ehi mdc benh khi benh nhdn cd kem theo tinh trang suy giam mien djch, dung cortieoid lau ngay, hoac sd dung cdc dung eu y khoa. Ngdy nay, cdc nha nghien cdu nhdn thay sd xuat h i i n cOa cac ehiling Pseudomonas aeruginosa mac phdi trong cdng d6ng, chilng ndy gay benh tren ngUdi khde manh, nhiJ nghien cdu cua tdc gid Huang YC [3]. Cd le, ehfnh vi sU khac nhau eCia ehCing Pseudomonas aeruginosa mdc phdi trong cdng ddng hay trong benh vien ma dac d i i m ve de khdng khang sinh cung khac nhau.
5. Ket l u a n
Khao sat 37 benh da bdng nudc tU mien ve loai vi trung va khdng sinh cho thay:
S. aureus khang methicillin gap nhieu nh^t (60,7%), tiep den P.aeruginosa 28,6%, S.aureus nhay methicillin 21,4%.
S. aureus nhay methicillin khang cao vdi penicillin, gentamycin, clindamycin, chloramphenicol, erythromycin.
S. aureus khang methicillin khang cao vdi penicillin, cefotaxime, ciprofloxacin, gentamycin, erythromycin.
P. aeruginosa khang eao vdi tetracyclln, co-trimoxazol.
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Tai lieu tham khdo
1 Abramczyk ML et al (2003) Nlssocomial infection in a Pediatric intensive Care Unit in a Developing country. The Brazilian journal of infectious diseases 7(6): 375-380.
i . AimeeSP, John RS {20M) Disorders of epidermal and dermal-epidermal adhesion and vesicular and bullous disorders. Fitzpatriek 8th edition, the McGraw-Hill Companies: 586-616.
3. Huang YC et al (2002) Community-acquired Pseudomonas aeruginosa sepsis in previously healthy infants and children: Analysis of forty-three episodes. Pediatric Infect Dis J 21 (11): 1049-1052.
4. Nguyen Thanh Bdo va Cao Minh Nga (2011) Chon lua khdng sinh ban dau trong dieu tri nhiem khuan benh vien tai mdt sd benh vien tgi TPHCM.
5. Nguyen Thj Dieu My (2012) T^ ii vd cdc yeu td nguy CO gdy nhiem khuan binh vien tren binh nhdn ton thuang da hd tgi Binh viin Da lieu thdnh phdHd Chi Minh. Luan van tdt nghiep chuyen khoa 2. Dai hpc Y DUpc thanh phd Hd Chf Minh.
Sarginson RE et al (2004) infection in prolonged pediatric critical illness: A prospective four-year study based on knowledge of carrier state. Critical care Med 32(3): 839-847.
Stanley (2008) Pemphigus. Fitzpatrick's Dermatology of general medicine 7th edition: 459-468.
Tim So Thea (2001) Nghiin cdu tinh hinh, ddc diem Idm sdng, cdn Idm sdng va ket qud dieu tn benh bang cortieoid tgi Binh vien Da lieu Trung uang td ndm 1995-2000. Luan van Thac sT y hpc. Dai hpc Y Ha Ndi.
Tran Ngpc Anh (2010) Nghien cdu ddc diem Idm sdng vd tu khdng the cda mot so benh da bdng nudc tu mien tgi Benh vien Da lieu TPHCM. Luan dn Tiln sT y hpc.
Trudng Dai Hpc Y Ha Ndi.
